1. Case History #3 “T”

2. 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

3. 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

4. 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

5. Assessment Due to medical conditions, accurate assessment results were difficult to obtain Intellectual: Significant cognitive and language disabilities Adaptive behaviors place him below 1 st percentile Functioning below 3-6 month level based Adaptive Behavior Assessment System (ABAS) Behaviors considered stable

6. 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

7. 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)

8. 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)

9. 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%)

10. 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

11. 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…”

12. 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

13. 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

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

15. 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

16. Seating and Positioning Device accessed while sitting/or positioned on his back Able to be mounted on wheelchair

17. 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

18. Motor Control Direct selection: Does he have control over any of these? eye gaze eye blink switch use grunt

19. 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?

20. 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

21. AAC Options ETran Simple Switch Use Establish cause and effect Switch combined with Step-by-Step or other communicator ERICA System (future goal)

22. 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?)

23. 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?

24. Discussion What are your thoughts? What questions would you ask if you were going to our meeting tonight?

25. 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