Case History Intake
Age 7 years-1 month
Case history intake was completed by Tina K. Veale, speech-language pathologist, via in person interview with Joshua’s mother, Paula. Here are the salient points noted from the intake interview.
Family hx: Joshua lives with his mother (master’s degree, librarian, stay-at-home mother), father (master’s degree, chemical engineer), and 10 year old sister in a complete family unit. His sister’s developmental history was unremarkable; she is a gifted violinist. There is no history of developmental concerns in second or third order relatives.
Birth hx: Pregnancy and delivery proceeded without complication. Joshua was born at 39 weeks gestation, or full term. He was a healthy newborn with no adverse medical issues, weighing 6 pounds, 3 ounces. He was not a vigorous eater as an infant, but gained sufficient weight to be on the low average end of growth expectations. Feeding therapy was not recommended.
Early dev hx:Reached developmental milestones for motor skills at slightly delayed ages (rolled over at 5 months; sat up at 8 months; walked at 14 months). Continued to exhibit clumsy motor patterns when walking, running, throwing/catching balls, etc. Unable to skip or ride a two wheel bike without assistance. Pedaled a tricycle and now a two wheel bike with training wheels with adult direction and physical prompts. Reduced overall muscle strength and coordination. Gait remains loose, but not ataxic. Joshua attended physical therapy from 2-3 ½ years of age to improve core muscle strength, walking and running patterns. He attended occupational therapy from 3-6 years of age to address fine motor development, including use of writing implements and scissors and dressing skills. He did not attend feeding therapy; although, he has always been a picky eater with a limited food repertoire.
Cognitive development proceeded on time or slightly ahead of norms. Joshua has always loved to learn one-on-one with a familiar adult. He learned basic concepts early and over-focused on them one at a time, enjoying the mastery of colors, shapes, sizes, numbers, and the alphabet. He started reading words aloud by 3 years of age, in books and on environmental signs. By 4, he could read several books aloud. Comprehension was pretty good, too.
Communication skills have lagged behind expected norms. Joshua did not follow directions given by adults, and while he was reading aloud, he didn’t talk as much as other kids his age. First words emerged at 2 ½ years, two word combos at 3 years. Joshua began speech-language therapy at age 3 years-2 months. Simple sentences emerged at 3 ½, and with private therapy three times per week, sentence complexity soon improved, as well. Speech intelligibility has always been reduced for his age, with multiple articulation errors and the use of a high-pitched, slightly nasal voice as contributing factors.
Medical hx: Joshua presented recurrent otitis media from the ages of 2-5 years when an otolaryngologist recommended PE tube placement. Since that time, he has had no further ear infections. Joshua suffers from seasonal allergies, and takes Claritin to relieve these symptoms.
Joshua was referred by his pediatrician for physical therapy at age 22 months; for occupational therapy at age 33 months; for speech-language therapy at three years of age. His parents initiated a developmental assessment at age five years prior to school enrollment due to motor, communication and behavioral concerns. He was diagnosed with autism spectrum disorder, level 1, and concomitant attention deficit disorder and sensory integration disorder.
School hx: Joshua began kindergarten at the age of 5 with special education supports given his recent diagnosis of autism, a mandated eligibility category for special education. He was mainstreamed with the support of a classroom paraprofessional who served Joshua and two other children in the class. Joshua’s goals focused on improved attention, turn-taking, and social politeness. He also had a behavior plan for reducing aggressive behaviors in class, such a pushing, kicking or hitting when he became upset.
Joshua attended first grade with the support of a classroom para, and is currently in second grade with no in-class supports. He continues to receive OT and SLP services at school and privately. Joshua’s academic progress is average to above average. He excels in mathematics and reading. He continues to struggle with fine motor skills (writing; typing), gross motor skills (physical education), communication and social skills (language comprehension and expression—oral and written modalities; adult and peer interactions). Joshua no longer exhibits aggression toward others when he becomes upset, and is working on self-regulation skills of asking for time out or telling the teacher what is upsetting him before he gets too uncomfortable. He continues to work on self-regulation of anxiety and modulation of his behavior at home and at school.
Purpose of the current evaluation: To reassess Joshua’s communication and social skills for current levels of functioning; establish age-appropriate goals for his individualized educational plan at school and for plan of care in private speech-language therapy; assess if other services are necessary at this time.