Case History #3“T”

Background 7 year old male Extensive medical history Significant cognitive, language, and physical

disabilities Attended Kindergarten last year, but now homebound

due to medically fragile condition Communicates primarily with eyes Receives speech therapy twice monthly at home

through Hermantown Public Schools

Medical History Sensory/Physical/Health Status:

Post shaken baby syndrome (occurred at 8 months) Cerebral Palsy Seizure Disorder Developmental Delay Serious Progressive Neuromuscular/Paralytic Scoliosis G-tube for eating Tracheostomy Spastic Quadriplegia Reactive Airway Disease Susceptible to respiratory infection Medically Fragile

Medical History Vision:

Cortical Visual Impairment Large circular movements of eyes when fixating on

object Holds eye gaze when approximately 6 inches from eyes Glare from lighting interferes with ability to visually

attend Requires visual breaks Wears correction Able to maintain eye gaze to identify pictures

Assessment Due to medical conditions, accurate assessment

results were difficult to obtain Intellectual:

Significant cognitive and language disabilities Adaptive behaviors place him below 1st percentile Functioning below 3-6 month level based Adaptive

Behavior Assessment System (ABAS) Behaviors considered stable

Assessment Hearing:

Appears to hear adequately, sometimes moves head slightly in direction of sounds

Assessed next school year by the audiologist

Perceptual: Unable to explore textures Responds to touch

Assessment Social:

Does not respond well to unfamiliar adults Will respond to simple commands when in good health and not

fatigued (e.g., lift your arm) Will initiate crying or facial expression when cold or hurt Will smile and occasionally laugh Seems to enjoy peers Able to differentiate between environments (e.g., home,

doctor’s office)

Assessment Cognition:

Difficult to test Speculate knowledge is higher than checklists indicate Uses eye movement to indicate yes/no Has identified pictures (e.g., familiar objects, body

parts)

Assessment Pre-Academic Skills:

Brigance Diagnostic Inventory (used in part) Results may not be accurate, but indicate potential to learn

academically Areas tested include the following:

Categories of nouns (e.g. food or animals) 6/8 (75%)

Personal Information (e.g., age or gender) 2/4 (50%)

Concepts (e.g., same/different or colors) 10/13 (76%)

Time Concepts (e.g., year or day) 1/3 (33%)

Assessment Daily Living Skills:

Tube fed Completely dependent on caregivers Physical conditions prevent him from assisting with care Strengths: enjoys bath and shows reaction to be wet/soiled Needs frequent humidity Uses manual wheelchair Not able to withstand long periods in sitting position

Uses body jacket brace and leg foot positioning braces

Assessment Communication:

Able to request, protest, greet, show interest, play, seek approval, agree, disagree, indicate that he doesn’t know

Non-verbal Fatigues quickly Attempted right cheek switch and step-by-step communicator, but access was

inconsistent and dependent on health and fatigue Currently uses right eye gaze for yes and left eye gaze for left Needs a more effective, efficient, and formal communication system A good intentional switch access has not been found due to severe physical

limitations “But…appears very ready for an augmentative communication device…”

Additional Comments from IEP No access to computer at home Suggested to video tape classroom lessons for

him to watch at home Able to watch TV mounted near his bed ERICA System evaluation noted as the first step

in an intentional movement evaluation

Treatment Very limited due to medical fragility Surgery not an option because he may not

survive Limited contact with DCD educator and SLP IEP does not state specific goals

Meeting with SLP will help identify goals

AAC Assessment Components: Communication Needs Seating and Positioning Visual Status Motor Control Switch Assessment Cognitive and Language Assessment

Communication Needs Interview (include SLP and foster parents)

Communication partners Communication mode

Strategies Interest in activities (computer use) Family’s feelings on current & potential

communication systems Environmental considerations during evaluation

Seating and Positioning

Device accessed while sitting/or positioned on his back

Able to be mounted on wheelchair

Visual Status

6 inches from eyes and slightly below eye level

Need to find optimum size, color, shape

Need to determine type of “correction” mentioned in IEP

Motor Control Direct selection:

Does he have control over any of these? eye gaze eye blink switch use grunt

Switch Assessment

We want more information about past use and reasons why it failed

Can we use body parts other than cheek to access the switch?

Can we vary body parts used to prolong attending and decrease fatigue?

Is there support for switch use at home?

Cognition and Language Assessment Informal Assessment of Eye gaze

Compare four directions vs. two (e.g., ETran) Maintain eye gaze for period of time Evaluate ability to use eye gaze to answer more than

yes/no questions Evaluate ability to attend before he fatigues Evaluate cause/effect

AAC Options ETran Simple Switch Use

Establish cause and effect

Switch combined with Step-by-Step or other communicator

ERICA System (future goal)

List of Questions for our Meeting today Information about T:

Can he control blink? Eye gaze? Switch? (selection method; what do we have to work with?)

Exactly what does he need to communicate? Humidity? Do we need to accommodate? Can T follow directions enough to direct gaze repeatedly at objects? x/second? Vision portion describes best positioning (at eye level & 6 inches away) what about size? Vision perspective, are any colors preferable? Who is coming on Friday? What position is best for us to interact w/ him? At table? Us on floor? Us on kiddee chair? Hobbies/interests? Doesn’t react well to unfamiliar adults/any suggestions here? How long until fatigues? Why aren’t we assessing him in his home? (consider medically fragile; natural

environment; fear of unfamiliar adults; more info for us; IEP discusses recognition of dr’s office environment, how will he react to our clinic?)

List of Questions for our Meeting today AAC use past/present:

Why are they interested in ERICA? For what activities was the switch used? Is it used at all now? Was it used to teach cause and effect? When did it work; when didn’t it work? How do they see the device being used at home and at school? What types of responses do you want to be able to generate from an educational

standpoint? Same for communication standpoint? Is it important for him to communicate while sitting & lying down? Is it important to

use a system that allows him to communicate from a variety of positions? What are his educational priorities & how do you see an AAC device assisting in this

area? If we do use a switch, is cheek only option? Can we switch cheek to prevent fatigue? Why was step by step communicator abandoned?

Discussion What are your thoughts? What questions would you ask if you were

going to our meeting tonight?

List of Questions for our Meeting today Extra areas to evaluate:

Can T understand cause and effect? What selection method will work? Eye gaze board assessment (ETran) Step by step (or other simple) communicator w/ switch

Ideas: Look in dev psy book for 3-6 month old development review Check CRC for some developmental scale protocols we could

adapt Do most important items at beginning; plan for fatigue