1. ADHD and Dysexecutive Functioning Syndrome
Case Study
ADHD and Dysexecutive Functioning Syndrome
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2. 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
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3. Initial Evaluation – 5/19/2016 Phase 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
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4. 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
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5. 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
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6. 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
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7. 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
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8. 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
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9. 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
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10. 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
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11. 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
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12. 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
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13. 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
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14. 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”
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15. 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
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16. 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
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17. 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
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18. 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
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19. Interactive Metronome Comparison of Long Form Test
Day 1
Task MS
Early Hits
Late Hits
Both Hands
217 36 17
Right Hand
252 23 7
Left Hand
271 31
Both Toes
148 1 3
Right Toe
N/A
Left Toe
107 20 4
Both Heels
103
Right Heel
Left Heel 87
Right Hand/Left Toe
138 14
Left Hand/Right Toe
113 13
Bal Right Tap Left Foot
Bal Left Tap Right Foot
Both Hands w/ GS
134 48 6
Total Unadjusted
196.2
82.3%
17.7%
Day 10
Task MS
Early Hits
Late Hits
Both Hands 39 34 19
Right Hand 43 23 7
Left Hand 56 24
Both Toes 59 16 14
Right Toe 99 4 18
Left Toe 57 8 21
Both Heels 62 10
Right Heel
196 15
Left Heel 64 11
Right Hand/Left Toe
122
Left Hand/Right Toe 67 9
Bal Right Tap Left Foot
235 13 17
Bal Left Tap Right Foot
266 30 1
Both Hands w/ GS 37
Total Unadjusted
100.1
55.8%
44.2%
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20. Interactive Metronome Comparison of Averages
Day 1
Battery Results, Millisecond Accuracy MS
Hands ms avg
218.5
Feet ms Avg
107
Both Hands ms avg
175.5
Both Feet ms avg
N/A
Left Side ms avg
189
Right Side ms avg
252
Bilateral ms avg
Adjusted ms avg
162.8
Highest IAR 2
Total Bursts
% within 15 MS
5.2%
Attend over time
172.9
Day 10
Battery Results, Millisecond Accuracy MS
Hands ms avg
43.8
Feet ms Avg
129.8
Both Hands ms avg 38
Both Feet ms avg
60.5
Left Side ms avg 59
Right Side ms avg
112.7
Bilateral ms avg
94.5
Adjusted ms avg
86.8
Highest IAR 4
Total Bursts 1
% within 15 MS
18.2%
Attend over time
88.5
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21. 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
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22. 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
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23. 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
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24. Pre-Testing for ReadON – 11/11/2017 Post 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.
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25. Further Recommendations
Continue Interactive Metronome Training
Advanced ReadON training
SLP for written expression
Monitor emotional expression
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26. https://maudeleroux.com/
Maude Le Roux, OTR/L, SIPT, IMC
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