All districts do things differently, so there may be some aspects of this case study that do not align with your district's procedures. The purpose of this study is to show the general process of beginning early intervention services and the roles of occupational therapy, physical therapy, and speech-language pathology in treating a child in early intervention.
SCENARIO: Jacob is an 18-month-old boy who was referred to early intervention services through his pediatrician on February 1st. He was born at 31 weeks gestation, stayed in the NICU for 4 weeks, and has been in relatively good health since then, apart from frequent ear infections. Jacob was recently diagnosed with spastic hemiplegic cerebal palsy (left side affected). Jacob's parents are most concerned because Jacob is crawling in a strange way, is not standing, gets frustrated when feeding himself, and has not yet said any words.
INTAKE: Three days after receiving the referral, the early intervention services coordinator contacted Jacob's family to set up a time to conduct an intake meeting. The intake meeting took place in the family's home on February 7th where the services coordinator and the family discussed the family’s concerns, questions, and priorities, and briefly overviewed Jacob's current level of participation.
After this meeting, the services coordinator sent the signed permission forms and paperwork from the intake meeting to the school district. The school district then contacted the occupational therapist (OT), physical therapist (PT), speech-language pathologist (SLP), and psychologist in the school district to notify them of the need to evaluate Jacob. The psychologist determined that she did not need to evaluate Jacob, but informed the other service providers and the services coordinator that they could contact her if any concerns arose regarding Jacob's mental health. The OT, PT, and SLP decided among themselves that the OT and PT would evaluate Jacob and inform the SLP of Jacob's language concerns based on parent report and observations. The next day the OT and PT contact the family to set up a time and date to come to Jacob's home to evaluate him.
EVALUATION: On February 20th, the OT and PT performed the evaluation using the DAY-C, which includes assessments of cognitive, fine motor, gross motor, adaptive, social/emotional, and communication development, and the Peabody Developmental Motor Scales (PDMS-2), which assesses stationary, locomotion, object manipulation, grasping, and visual-motor integration activities. During the evaluation the OT and PT also asked the family about their questions and concerns related to Jacob's development.
In the following week, the OT and PT scored their evaluations and found that Jacob was delayed in the fine motor, gross motor, communication, and adaptive areas according to the DAY-C, and delayed in the stationary, locomotion, object manipulation, grasping, and visual-motor integration areas according to the PDMS-2. OT and PT decided that Jacob would qualify for their services. They communicated with the SLP that Jacob scored poor in the communication domain and that parents were concerned that Jacob has not yet said "mama," "dada," or any other understandable word. The SLP decided that Jacob would also qualify to receive speech services.
CHILD AND FAMILY ASSESSMENT: The services coordinator and SLP set up a time with Jacob's family to conduct the child and family assessment using the Routines-Based Interview (RBI). They went to the family's house on February 28th to perform the RBI, during which they gathered more in-depth information about the family's concerns and priorities for Jacob and the family as a whole, their daily routines and Jacob's participation during those routines, and personal information that would allow the team to get to know the family better and understand their concerns. The family identified crawling, feeding time, and talking as their primary concerns and priorities.
MDT AND IFSP MEETINGS: The services coordinator set up a combined Mulitdisciplinary Team (MDT)/Individualized Family Service Plan (IFSP) meeting for March 8th and sends a Prior Written Notice document to the family 10 days prior to the meeting to notify the family in writing about the time and date of the meeting. In attendance at this meeting was the services coordinator, OT, PT, SLP, a representative from the school district (elementary school principal), and Jacob's mother and father. During the MDT portion of the meeting, the service providers discussed the results of the evaluation and explained that Jacob does qualify for services. During the IFSP portion of the meeting, the service providers and parents discussed the frequency and duration of services to be provided and appropriate outcomes for Jacob and his family.
SERVICES BEGIN: Within 30 days of the initial IFSP meeting, OT, PT, and SLP begin seeing Jacob.
The occupational therapist visits Jacob twice a month. On their first visit, the OT addressed Jacob's feeding by practicing feeding while sitting in a high chair at the kitchen table where Jacob typically eats meals. He was offered applesauce from a hard plastic bowl, small slices of oranges, and juice from a sippy cup with no handles. The OT noticed that the environment was very busy (the TV was on, the family's two big dogs were licking Jacob's arms, Jacob's older brothers were being loud) and caused Jacob to move his head a lot, looking toward the sound. When he turned his head, the OT noticed that his hand and arm movements appeared uncontrolled. The OT also noted that Jacob did not use his left hand to assist with feeding. The OT advised the family to help Jacob try to use his left hand to stabilize his bowl with hand over hand assistance. The OT demonstrated how to do this, then asked the family if they wanted to practice and get feedback while the OT was there with them. They said "yes" so they practiced and the OT gave them positive and constructive feedback. The OT offered to bring the family one of her non-slip placemats to place under Jacob's plates and bowls when he is eating so they are less likely to slip and slide on the tabletop. The family agreed so the OT noted to bring the placemat to the next session.
When finished with his snack, the OT tested Jacob for a retained reflex called the Asymmetrical Tonic Neck Reflex (ATNR) which is supposed to disappear around 6 months of age and found that Jacob's ATNR was still retained. With this reflex, the arms involuntarily move in response to head movement. The OT recognized that this reflex may be part of the reason it is so difficult for Jacob to feed himself, especially since he eats in a busy environment. The OT educated the parents about the ATNR and suggested that they try to reduce the business of the environment by turning off the TV and taking the dogs outside or into another room when Jacob is eating, so that he is less likely to turn his head when eating and therefore will have greater control over his arm movements. The OT also educated the family to play with balls with Jacob including rolling, catching, and throwing, as these activities can help to integrate the ATNR. Also to help integrate the ATNR, the OT educated the family about how to encourage reciprocal movements when Jacob is crawling, by physically helping Jacob move his extremities in a specific pattern. Again, the OT demonstrated how to do this and then the family practiced.
In future sessions, the OT followed up about how the family was doing with the suggested activities. They also addressed ways to incorporate bilateral hand use in play activities and weight-bearing through Jacob's left arm to increase his proprioception (knowing where his arm is in space), hand and arm strength and coordination, and potentially decrease flexor tone in his hand.
The physical therapist visits Jacob once a month. On their first visit, the PT addressed Jacob's crawling. When Jacob crawled, he would use his right arm and right leg to do all the work while his left arm would rarely touch the ground and his left leg would hardly move at all. The PT first did some light stretching to Jacob's elbow, wrist, hand, and knee so that his arms and legs could function optimally when later practicing crawling. The PT demonstrated to Jacob's mom how to do this stretching then asked if she wanted to try it out. She agreed to try it for practice and the PT gave her feedback.
The PT then practiced weight bearing exercises in the quadruped position so that Jacob's left hip and shoulder could gain strength and endurance and get used to bearing weight, so that he would be more capable of using his left arm and leg to bear weight during crawling. The PT used a firm pillow as a bolster under Jacob's tummy and made sure that Jacob's knees and arms were directly under him and not out to the side with one leg or arm doing more work. The PT suggested putting a puzzle or light-up toy in front of Jacob during this exercise and encouraging Jacob to use his right hand to engage with the toy while his left arm is weight-bearing. After demonstrating, Jacob's mom then took a turn trying this strategy. Finally, the PT had Jacob practice crawling while trying to incorporate more movement from the left arm and leg. The PT demonstrated how to facilitate the movements with physical assistance and had Jacob's mom practice.
In future sessions, the PT followed up about how the stretching, quadruped activities, and crawling were going. The PT also addressed pulling up to stand, offering suggestions such as putting a motivating toy on top of the coffee table so that Jacob would want to stand to get it, then assisting him in pulling himself to stand.
The speech-language pathologist visits Jacob twice a month. On their first visit, the SLP asked Jacob's parents if he has been using more words or sounds since the last time she saw them. After hearing that he has not been using noticeably more sounds, the SLP gave Jacob's parents some tips about how to encourage increased speech. The SLP suggested turning the TV off when trying to get Jacob to communicate or copy the parents so that their words could be clearly heard and understood. The SLP then suggested using simplified and repetitive language during daily routines, explaining to Jacob what they are doing to encourage him to imitate them. The SLP demonstrated this when Jacob brought over a closed box of toys and wanted it opened. The SLP said, "you want box open?" before opening it, "okay, open box" when opening it, "box open" when the box was opened. The family agreed to practice this a few times while playing with Jacob and the SLP gave them feedback each time.
The SLP then educated the family to encourage Jacob to make any type of sound productions such as what animals say or sounds in response to you trying to get him to imitate and praise him immediately when he does make a sound, whether or not it sounds exactly like the whole word, then repeat the word you were trying to get him to say. The SLP demonstrated this by reading a book with animals in it, asking him to imitate a cow sound "Moo", Jacob said "mmm", the SLP said "yes, moo! Good job." The parents then practiced this while playing a game with blocks. The SLP taught the parents to give Jacob one block, put more blocks where he can see them but out of his reach, say "say block", wait for Jacob to make a sound such as "bah", then immediately give the block to Jacob and say "good job! Block!" They practiced this a few more times with the blocks and when Jacob started becoming frustrated, the SLP taught them not to push Jacob too far and to give him the blocks even if he didn't say it, saying "block," each time.
In future sessions, the SLP followed up with the family about how the new strategies were going and gave them more strategies to try including talking to Jacob at his eye level when talking to him so that he can see their mouth, pointing to their mouth when saying a word that they want Jacob to imitate, following Jacob's lead about what he is interested in and use that activity to practice speaking, and using consistency with phrases used during daily routines.