ANNUAL DEVELOPMENTAL ASSESSMENT REPORT

 

Name: Rose McAuliffe                        
Date of Birth: 2-26-99                       Parents: Cheryl and Chris McAuliffe
Chronological Age: 13 1/2 months                                    
Date of Assessment: 4-13-00

REFERRAL INFORMATION

Rose was referred to the Stepping Stones Birth to Three program at four days of age by her mother. Developmental services were requested as Rose is determined to be developmentally at risk for delays due to her diagnosis of Down Syndrome.

HEALTH REVIEW

The following information was obtained from Mr. and Mrs. McAuliffe and from medical reports received by Stepping Stones. Mrs. McAuliffe reports having a relatively healthy pregnancy. An amniocentesis done in September 1998 diagnosed the baby with Down Syndrome. Subsequent echocardiograms also diagnosed her with having an endocardial cushion defect and a large AV canal for which surgical repair would be required. The family was placed in contact with the Genetics Clinic at UCONN (Sally Rosengren, MD) and also with the pediatric cardiology group at CCMC (Drs. Leopold. Ellison and Diana). Rose was born at full-term at UCONN Health Center via a C-section delivery secondary to footling breech positioning. She weighed 3640 grams and her APGAR scores were 3 at one minute and 8 at five minutes. Neonatal complications included acute respiratory distress and significant GE reflux. Rose was found to have a duodenal web which resulted in the need for a duodenostomy and placement of a 0-tube. When Rose was finally discharged home at 28 days she was receiving primarily G-tube feedings. On 6-14-99, Rose underwent surgical repair of the AV canal. The surgery was complicated by pulmonary hypertension requiring ECMO in the PICU. Although the initial prognosis following removal from the ECMO was poor, Rose rallied and did well, being discharged home from CCMC on 7-2-99.

Rose has continued to do remarkably well physically and developmentally. She now weighs approximately 16 1/2 lbs and is taking primarily oral feeds. With the exception of having bronchitis in February, Rose has stayed relatively healthy. Primary pediatric care is provided by Dr. M. Levine who is also monitoring Rose's weight gain.

Toward the end of July 1999, Rose had her cardiac follow-up appointment. It was noted that the repair looked good, however, there was some residual mitral insufficiency which did not require intervention at the time. On 1-19-00, Rose was seen by Dr. Bob Greenstein, geneticist. He felt that she was doing well and recommended a follow-up just before Rose's third birthday and prior to her entering a preschool program. He also recommended an audiological assessment which as done at CCMC on 2-25-00. At that time Rose had fluid in her ears which reportedly effected her tympanograms. It was recommended that she return for a re-assessment after her ears were clear. This appointment has not yet been scheduled.

Rose receives weekly early intervention services to address all areas of her development from Karen Rusling-Tiemann, physical therapist from Stepping Stones. She also is seen every three months by speech and language therapist and clinical dietician on an as-needed basis. Speech and language therapy/oral motor and feeding will be increased.

Rose has done so well in great part due to the wonderful, loving and appropriately stimulating environment of her home which she shares with her parents and two older sisters, Erin and Katie.

ASSESSMENT PROCESS:

This assessment was completed in the family's home with Rose and her mother present. Members of the assessment team included Mrs. McAuliffe and Karen Rusling-Tiemann (physical therapist) and (speech pathologist) from the Stepping Stones Birth to Three Program.

The evaluation was completed in English. The Battelle Developmental Inventory (BDI), parent report, home visit notes and clinical observation were used to complete the developmental portion of the evaluation.

DEVELOPMENTAL AREAS

Personal-Social Domain:

Rose is typically a very happy, social baby. She greets familiar people, especially her immediate family members, with big smiles, vocalizations, and waving "Hi". She enjoys physical and social games and is beginning to actively participate in peek-a-boo. Rose will engage others using eye contact, touch and vocalizations ("yelling" to get attention). She will also reach out and explore facial features of familiar people. Rose has demonstrated some stranger anxiety in the past couple of months, however, this does not seem to presently be an issue for her. She is very visually vigilant of her mother's whereabouts and will turn and look for her when she leaves the room. Rose also looks toward and reaches out for her parents for comfort. Rose recognizes her name when called. When given a mirror, Rose will wave at and kiss her mirror image.

Gross and Fine Motor

The quality of many of Rose's movements as well as her overall acquisition of motor skills is directly influenced by her generalized decreased muscle tone and decreased proximal stability. Rose has been, until recently, very resistant to being placed on her stomach. She now has "found mobility" and will purposefully roll around to obtain a desired toy or to get near a favorite person. She will tolerate being on her stomach for longer periods of time and can now reach for an object in this position (prone on forearms) demonstrating emerging weight shift. Rose will briefly maintain a hands and knees position (quadruped) when placed. She now sits independently with her trunk erect and her hands free to play while demonstrating emerging balance. Her protective responses are also just emerging to the front and to the sides when in sitting. Rose will move from independent sitting to being on her stomach using a " slow, controlled fall" to the sides or move forward through her straddled legs. For the past couple of months, Rose has been placed in supported standing on a very slow moving treadmill using a protocol established by D. Ulrich at the University of Michigan. In their studies, the use of the treadmill in this way has been shown to facilitate onset of walking skills in infants with Down Syndrome. Rose has shown significant improvement in extending her legs and bearing weight on her feet in supported standing. She will now stand with support placed at her upper trunk and take beginning steps with facilitation.

Rose reaches directly and purposefully for a desired object with both hands. She uses an immature raking grasp bilaterally (using fingers to pull the object into the palm of her hand) to pick up small objects such as a Cheerio. Complete thumb opposition is noted when picking up larger objects. Rose uses an assistive release when letting go of objects in her hands (ie. throwing). She is able to remove rings from a stacking post independently and take objects out of a container. Rose will hold an object in each hand and bang them together. Better hand use is noted when she is positioned with increased proximal support (ie. Rifton chair with a tray).

Communication

Receptive Language: Rose is a very attentive baby who is focused on the sounds, and especially the voices, in her environment. She is a baby who listens. She responds to different tones of a person's voice. When her mother asks in a questioning tone "who's home?" , Rose looks excitedly toward the door where she expects a family member to enter. She associates words with familiar actions, such as time to eat or time to take a bath. Soon she will. look towards each one when named s a beginning step to identify them by name. Rose also enjoys looking at picture books and having her family name items in the books.

Expressive: Rose is a vocal baby. She will yell out for attention and she has a wide range of sounds for various emotional states. She is babbling in long strings of consonant and vowel combinations including the following sounds: d, g ,w, h, y, b, p and m. Rose enjoys experimenting with changes in pitch and volume of her voice. She uses some gestures as well to get her needs met. Rose will lift her arms up when asking to get picked up. She will push away what she does not want. She also shakes her head "no" and is beginning to get "yes" although she is not using these appropriately at this time. She does wave her hand appropriately for "hi" and "bye" often with the verbal prompting. Rose enjoys games of reciprocal sound play. She is imitating motor movements readily and watches a speaker's mouth carefully in what looks like an attempt to imitate sounds. These observations lead one to believe that Rose might begin to imitate new sounds soon.

Cognition

Rose explores her environment visually and she shows interest in new objects and surroundings. She rolls to get to a new or preferred toy. She feels and explores objects carefully. Rose likes to take objects out of containers and watch them fall. She activates the pieces on her activity table with enthusiasm. Rose has recently begun to activate many different types of cause and effect toys. She will pull a string to obtain a toy and reach around a see-thru barrier to get the toy on the other side. This demonstrates that she is using beginning problem solving skills. Rose will look for a removed toy indicating the she remembers the toy when it is out of her sight (visual memory/object permanence).

Adaptive

Attention: Rose is very attentive to people, objects and activity in her environment. She uses her eyes together to visually track an object as it is moved in a vertical, horizontal, circular or diagonal path. She is primarily interested in social interactions, however, Rose is beginning to spend longer time with toys and books when an adult or older sister is playing with her.

Self-care skills: Rose is eating a variety of baby, foods and some first finger foods. Her family has been given sensory and oral motor suggestions to assist in her oral motor and feeding development which appear to be helpful. Rose will open her mouth in anticipation of the spoon and she is now starting to use her lips to remove food from the spoon. She will hold onto a cracker or cookie and bring it to her mouth. Rose now drinks from a bottle demonstrating complete lip closure and a strong suck. A small cup (medicine cup) with thickened liquids has been introduced. With jaw control, she is doing relatively well drinking small amounts of liquids at a time from the cup. Reportedly, Rose will pull her shoes and socks off.

Summary and Recommendations

Rose is a very happy, social 13 1/2 month old baby with a diagnosis of Down Syndrome. She has made remarkable developmental progress in the past several months following surgical repair of a heart defect last June when she was four months of age. There were severe complications during the surgery, however her recovery was remarkable and the repair was determined to be a success. Rose has remained relatively healthy since her discharge home from the hospital following the surgery. Rose receives wonderful stimulation from her very loving and attentive family. Rose's strengths are in her social and communication abilities. She uses a variety of vocalizations, facial expressions and gestures to communicate. Generalized decreased muscle tone and proximal instability have hampered Rose's gross and fine motor abilities, however, she appears to have had a "spurt" and is she now independently mobile through rolling and transitioning out of independent sitting. With her parents' persistence and patience, Rose is now receiving almost all of her nutrition via oral feedings (baby foods from a spoon/ some baby finger foods and liquids from a bottle and from a small cup). It is anticipated that she will be off of her G-tube feedings within the next month or so.

It is recommended that Rose continue to receive early intervention services which use a transdisciplinary approach to best address all areas of her development. In the upcoming year emphasis will continue to be on Rose's motor development, expressive and receptive communication skills and her oral motor/feeding skills

Any questions regarding this report may be directed to the evaluators at the Stepping Stones Birth to Three Program at 278-1100 ext. 281.

Karen Rusling-Tiemann, RPT                                                        MA CCC/SLP
Physical Therapist                                                                Speech and Language Pathologist

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