Name        : Mark (name changed)

Age             : 2.3 years 

Gender     : Male

Treatments :Speech Therapy and Occupational Therapy

Therapists

Sherine Shibu- Speech Language Pathologist

Silla George and Riya  – Occupational therapist

Reviewed by – Joan Annie Jacob and Anakha Pisharody

History

Master Mark, a 2.3 years old male child, came with his parents for assessment and therapeutic interventions. He is the 1st born to his parents and has a younger brother. Their mother tongue is Malayalam; he spends most of the time at home and has very less social exposure due to the pandemic. He is a pleasant boy, follows simple commands and always likes to be with his mother.

He had a shudder attack when he was 8 months old. He also had adenoids, for which adenoidectomy was done at the age of 2.4 years( which was after the initial speech assessment); it was after the surgery that the child had continued to attend speech therapy and occupational therapy sessions.

Mother’s age of conception was 26 years. She had excessive vomiting and Urinary tract infection during the gestational period. There were no other complications. He was a full-term baby and it was a normal delivery. He weighed 2.8 kgs at birth and had an immediate birth cry; adequate sucking was also present. His motor milestones were reported to be normal, whereas his speech milestones were delayed. At the time of assessment, he had around five words. The child had screen time during his early years (before 1 yr), which was more than 1 hour; he also did not receive much language stimulation at home as parents did not have guidance as to how to interact with the child as they were new parents.

Speech and Language Therapy

Communication and Language Profile before assessment

Mark was initially too scared to enter the assessment room since he had very less exposure outside his home due to covid protocols. He used to find difficulty adjusting to new places and didn’t prefer to be in closed spaces. He communicates nonverbally by dragging the caregiver to his desired item or by crying. He was also able to point at things he likes. His vocabulary mainly consisted of proto words.

Assessment

Parents’ concerns were that he was not speaking age adequately, did not have proper words, did not respond to names and communicated mainly in actions.

In the assessment session, he was able to play with a few toys, but there was not much exploration that could be observed; he did not give adequate eye contact nor respond to his name when the clinician called him. To assess his current language level, Assessment of Language Development Test (ALD) was administered, which gives us information regarding his understanding level (Receptive language / RLA) and his speaking level (Expressive Language /ELA). When Mark was 2.3 years old, his

Receptive Language Age (RLA): 18 – 24 months

Expressive Language Age (ELA): 6 – 12 months

His oro motor structures were examined, and it was noted that he had an open mouth posture, and other oral structures were structurally and functionally normal.

Intervention

The child was enrolled for a speech therapy session which was provided four days a week; each session was 45 mins. During the sessions, the clinician worked on goals that were taken according to his developmental levels and the last 10 minutes of the session was taken to explain to the mother how to interact with the child, what activities can be done at home and what modifications can be used to elicit verbal responses from the child. The mother was also given opportunities to work on the goals under the therapist’s supervision to provide feedback to the parent on how to work on the goals at home. The child’s mother was actively involved in the sessions, whereas the father used to come only once or twice a month due to his work. The following were the goals that were taken for Mark.

• Mark should be able to participate with the therapist in a play based activity which includes playing with bubbles, stacking rings, balls,etc for 5-10 mins in 3/3 trials.
• Mark should be able to greet the therapist by saying “hi” when he meets her and bid farewell to the therapist by saying “bye” in 3/3 trials.
• Mark should be able to take turns with the therapist to play games such as cutting fruits, stacking cups,etc in 3/3 trials 
• Mark should be able to imitate the actions of the therapist while singing rhymes like “wheels on the bus”, “twinkle twinkle” in 3/3 trials.
• Mark should be able to identify 5 lexical items like dog, cow, sheep,etc from animal category, apple, orange and banana from fruit category, eyes , ears, nose from body parts in 3/3 trials.
• Mark should be able to request for his snack or a toy using a monosyllabic word /tha/ and call his mother to come inside the therapy room by saying the monosyllabic word /va/ in 3/3 trials.

Outcomes

After three months of regular sessions, the child had shown drastic improvements. At present, he enters the room joyfully even though it is a closed space; and he spontaneously responds to the clinician when she greets him. Initially, Mark started to verbalize his needs using monosyllabic words, and gradually, he started using bisyllabic words in his vocabulary. At present, he is able to communicate in a 2-word phrase to express his needs or to bring other’s attention to something he sees. Initially, the child did not know common objects, animals, fruits etc., that he saw in his daily life, but after three months of therapy, he started to identify a minimum of 5 items from categories such as animals, fruits, vehicles, colours, body parts and common objects. Overall his vocabulary improved, and he is also able to generalize what he has learned in the sessions to other situations and appropriate contexts.

OCCUPATIONAL THERAPY

Mark’s occupational therapy assessment was scheduled after 2 follow up visits with the speech therapist. Mark was initially not very cooperative and was stubborn during the session as he was new to the environment. He tried to explore the toys and equipment in  the room but did not mingle well with the therapist. He was scared to navigate the swings and slides initially.

Assessment

The initial parental concerns included poor eye contact, poor name-call response, cornering of eyes, inadequate attention span and poor sitting tolerance.

During the initial assessment sessions, it was noted that Mark exhibited a fear of heights and specific play equipment such as swings, slides, merry-go-rounds, and small-height chairs. He lacked the knowledge of jumping and had difficulties with gross motor skills. Additionally, he displayed sensory behaviors such as closing his ears in response to specific sounds (trains, rain, crackers, carol songs) and staring at AC and sliding doors.

Activities of Daily Living: Mark was dependent on his mother for dressing, bathing, toileting (wears diapers), feeding (avoids green colored and sticky foods) and brushing his teeth and hair cutting (shows reduced cooperation).

Play: According to Parten’s play classification, Mark was in transition from solitary play to onlookers play, and according to Takata’s stages of play, he was in the sensorimotor epoch.

Social skills: Initially, Mark exhibited crying episodes when visiting other houses, especially relatives’ houses. He used to be involved in solitary play and didn’t mingle with his peers much. He displays greetings like “hi” and “bye” to familiar individuals, often in response to verbal cues, and occasionally initiates greetings on his own. 

Sensory behaviors: Toe walking was initially reported by Mark’s parents, although it was not observed during the assessment sessions. Other sensory behaviors reported included corner eye, self-laughter, hand flapping, lining up chairs, spinning, and fear of specific sounds and stimuli. Mark showed sensitivity to sounds such as vehicle noises, cooker whistles, and mixers. He displayed visual fixation on AC and sliding doors.

Intervention

Mark participated in occupational therapy sessions four times a week for a duration of three months. During the second month, he was also included in group sessions alongside his individual therapy. These sessions lasted for 45 minutes each and focused on activities tailored to address his specific goals. Additionally, Mark’s mother received counseling on implementing activities at home to support his progress. Sensory Integration Therapy was provided for him to address his sensory modulation issues and ADL training was provided to enhance his independence in ADLs.

Occupational Therapy goals were mainly taken to improve his cooperation in brushing and independence in dressing.

• Mark will be able to cooperate for brushing with minimum verbal prompt.
• Mark will be able to jump continuously on trampoline independently 

in 5/5 trials

Subgoals were as follows:

• Improve sensory processing and regulation skills.
• Enhance gross motor skills and fine motor skills.
• Address sensory sensitivities and behaviors.
• Improve social skills, including turn-taking, joint engagement, and interaction with peers.
• Develop play skills, such as cooperative play, imaginative play, and sorting and

categorizing objects.

• Enhance attention span and sitting tolerance.

Outcomes

After 3 months of therapy, the child showed tremendous improvement in terms of his gross motor skills especially jumping, navigating swings and slides and climbing. Mark’s attention span and sitting tolerance improved over the course of therapy sessions, indicating increased focus and ability to engage in activities for longer durations.

His fine motor skills like grasping and manipulating objects also showed drastic changes. Mark also exhibited improved independence in his ADLs like bathing, dressing, feeding and toileting and also increased cooperation in brushing and grooming. Mark’s hypersensitivity to specific sounds, as reported by his mother, reduced significantly. Additionally, self-stimulatory behaviors decreased, and he showed decreased fixation on specific visual stimuli, such as AC and sliding doors. 

Mark exhibited improvement in social skills. He has started to respond to name calls and maintain eye contact with others. He overcame his initial discomfort when visiting other houses, including relatives’ houses, and his crying episodes in such situations settled. He learned to greet others by saying ‘hi’ and & ‘bye’ and attempted to imitate prompted words. He has also shown progress in his play skills, as he now plays with his brother and peers. Mark’s pinching behaviour towards family members and other children has decreased.

At present, Mark is on a break from Occupational Therapy and Speech Therapy for a period of 1 month due to personal reasons hence home program has been advised to the parent and follow-up after one month has been recommended.

Discussions

When we look into the difficulties exhibited by Mark, we do see that Mark shows few features that are commonly seen in children with Autism Spectrum Disorder (ASD), but when we probe into the possibilities of why Mark had these features, we understand that it was because of excessive exposure to screens and lack of stimulation at home. When kids are engaged with screen time, they do not have an opportunity to speak with others, share the information they have seen in the video, respond to name when they are called, etc, because in most situations, screen time is provided for kids by the parents when parents want to get their jobs done and to engage the child. In the above-mentioned case, when screen time was brought to 0, many changes started emerging, and with intensive and early intervention, the child has shown significant improvement in all his domains. Hence from the study, we understand that excessive exposure to screens and lack of stimulation can cause a child to exhibit features of ASD, but with early intervention and reducing screen time, great improvements can be brought. The above case study is also in agreement with the article titled “Early electronic screen exposure and autistic-like symptoms” ***

***Hermawati D, Rahmadi FA, Sumekar TA, Winarni TI. Early electronic screen exposure and autistic-like symptoms. Intractable Rare Dis Res. 2018 Feb;7(1):69-71. doi: 10.5582/irdr.2018.01007. PMID: 29552452; PMCID: PMC5849631.

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Reference: https://prayatna.co.in/virtual-autism-how-to-deal-with-it/