Oregon Health Sciences University
Consultative Report
CHILD DEVELOPMENT AND REHABILITATION CENTER
P.O. Box 574, Portland OR 97207-0574
Name Harris, Calvin
Birthdate 02/22/1996
Account No.
Medical Record No. 01-44-75-05
CLINIC DATE: 03/12/1999
CLINIC NAME: CHILD DEVELOPMENT PROGRAM EARLY CHILDHOOD ASSESSMENT CLINIC
DISCIPLINE: PSYCHOLOGY/CASE COORDINATOR SUMMARY
REFERRAL AND BACKGROUND INFORMATION: Calvin Harris, a 3-year-old Caucasian male, was seen today for an interdisciplinary evaluation through the Early Childhood Assessment Team Clinic (ECAT). Calvin was referred by his mother, Katalin Harris, due to concerns regarding developmental delays and a desire for diagnostic clarification. An educational diagnosis of autism was made by Cascade Regional Autism Services in December 1998. Calvin was accompanied to clinic by his mother, Katalin Harris, and father, Timothy Harris. They were seen by the following professionals: Cynthia Hartung, Psychology Resident; Laurel Robertson, Psychology Intern; Kersti Pettit-Kekel, Occupational Therapist; Patricia Garlinger, Developmental Pediatrician; and Kathryn De Armond, Speech/Language Pathologist.
Calvin currently lives at home with his mother and father in Corvallis, Oregon. Calvin's medical history is benign and he is currently in good general health. Calvin attends daycare at Oregon State University (OSU) Kindercare. Calvin receives special services through Early Intervention. He receives speech services four times per month. Calvin was assessed through Linn-Benton-Lincoln Early Intervention Program -Benton County, and Cascade Regional Autism Services and diagnosed educationally autistic. A Battelle Developmental Inventory administered in May 1998 suggested that Calvin was performing over two standard deviations below the mean in social, adaptive, communication and cognitive domains. Since that evaluation and diagnosis, Calvin receives services twice monthly from the Regional Autism Center.
CURRENT CONCERNS: Calvin's mother reports concerns with Calvin's "selective listening," delayed speech, lack of memory, retention, lack of understanding regarding safety issues, poor eye contact, social delays, aggressive hand flapping, toe walking, obsessive behavior, and lack of response to his name. OSU Kindercare notes problems relating to other children and a preference for doing things on his own.
BEHAVIORAL OBSERVATIONS: Calvin presents as an appropriately dressed blond three year old. He came to the examination room well ahead of his parents at the request of the examiner. He ran all the way down two hallways before coming into the room. Calvin ran on his toes the entire way to the room and was observed clinching his hands and "running on the spot", an odd mannerism in response to anxiety or excitement. Calvin responded to his name inconsistently throughout the testing and displayed limited eye contact. He responded to joint attention cues only after several very animated attempts to engage.
Calvin did not relate directly with the examiner. He frequently leaned over this examiner during testing, making contact for balance purposes. Calvin was very difficult to direct in all activities and test items could only be administered if Calvin showed interest in the materials. His attention could not be gained for items in which he displayed no interest. Calvin interacted with many of the material by banging them on the table or pushing them off the table.
TEST RESULTS AND INTERPRETATION: Calvin was administered the Bayley Scales of Infant Development, Second Edition, Mental Scale. Administration was not completed in the standardized fashion due to Calvin's poor attention. Therefore, this assessment should be considered as a baseline estimate of his cognitive abilities. Based on his performance today, Calvin obtained a raw score of 124, which indicates a standard score of <50 and an age equivalence of 21 months. Calvin's score today suggests that he is significantly delayed in his cognitive skill development, approximately 15 months behind his same age peers.
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CLINIC DATE: 03/12/1999 Med Rec No.: 0144-75-05
Page 2 Name: Harris, Calvin
Mr. and Mrs. Harris were interviewed with the Vineland Adaptive Behavior Scale (VABS), Survey Edition. Based on responses by Calvin's parents, Calvin obtained an Adaptive Behavior Composite of 59 (age equivalent 17 months). His score is roughly commensurate with that obtained on the Bayley Scales of Infant Development, and suggests more global developmental delay. Calvin's subdomain scores were as follows: Communication = 67 (18 months age equivalent); Daily Living Skills = 66 (19 months age equivalent); Socialization = 5 8 (11 months age equivalent); and Motor Skills = 64 (20 month age equivalent).
During a structured interview of autism and pervasive development disorder symptomology, Mr. and Mrs. Harris reported that Calvin is unusually interested in the feel of certain things: his mother's hair and the carpet on his bare skin. He displays odd hand mannerisms, including pointing his finger. Calvin also lacks of sharing, emotional reciprocity, involvement in social games, and imaginary or cooperative play. Speech delays, including no use of short phrases or sentences, using his parents hands as a tool, lack of interest in friends or other children and lack of response when other children approach him are other behavior characteristics that Calvin displays that are consistent with a diagnosis of autism.
The Childhood Autism Rating Scale (CARS) was completed based on Calvin's reported and displayed behaviors. Scores obtained from this measure placed Calvin in at least the mildly-moderately autistic range. Of specific note was Calvin's lack of imitation and high activity level.
Calvin's parents were asked to complete two separate behavior checklists. In response to items listed as part of the Child Symptom Inventory, Calvin's parents endorsed many symptoms characteristic of a diagnosis of autism including: "does not play or relate well to other children," "not interested in making friends," unaware or takes no interest in other people's feeling," "has a significant problem with language," "has difficulty making socially appropriate conversation," "has a peculiar way of relating to others" and "talks in a strange way," "Difficulty paying attention," "does not seem to listen when spoken to directly," "difficulty following through on instructions," "easily distracted," "fidgety," "difficulty remaining seated," and "difficulty awaiting turn in group activities" were other items endorsed by Calvin's parents. On the Behavior Assessment System for Children - Parent Rating Scales (BASQ, items endorsed by Calvin's parents included distraction, trouble making new friends, trouble shifting gears from one task to another, short attention span, cannot wait to take turns, trouble concentrating, and overly active.
RESULTS FROM OTHER DISCIPLINES: Dr. Garlinger reported that she was unable to make a complete assessment of Calvin because he slept through the examination after a period of being difficult to console. Dr. Garlinger reported that Calvin is in general good health. His father started giving him vitamin B6, B 12, and magnesium in January, 1999 following his educational diagnosis of autism. Calvin's mother reported she was concerned with safety issues, although Calvin has never experienced any ER visits. Problems with sleep were denied and Calvin reportedly eats everything by stuffing it in his mouth but experiences no choking. At this point in time, Dr. Garlinger, due to extreme fatigue in the patient, did not feel comfortable in making a diagnosis of autism as an individual team member.
Kathryn De Armond, Speech/Language Pathologist, administered the Preschool Language Scale and reported a Receptive Language Score of 62 (17-month age equivalent) an Expressive Language Score of 72 (23-month age equivalent). She noted hand slapping, rigidity, limited play, and no eye contact during the evaluation. Results from the evaluation suggested that Calvin has a language disorder with no articulation problems at this time.
Ms. Pettit-Kekel reported that Calvin scored at approximately the 2 1 -month level on tests administered, but that this score should be regarded as a baseline given considerable scatter on Calvin's profile. Limited play, lack of eye contact, no imitation, or lack of following directions were noted behaviors in that exam.
CONCLUSIONS AND RECOMMENDATIONS: Calvin Harris, a 3-year-old male, was seen today for a comprehensive interdisciplinary evaluation. Results from assessment measures administered indicate that Calvin is globally functioning well below his age expectancy in all areas tested here today. Calvin therefore meets criteria for developmental delay.
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CLMC DATE: 03/12/1999 Med Rec No.: 0144-75-05
Page 3 Name: Harris, Calvin
In addition to his developmental delay, Calvin is exhibiting behaviors consistent with an Autistic Disorder, as outlined in the DSM-IV. These behaviors include lack of eye-to-eye gaze, lack of spontaneous sharing or activities or interests with others, lack of social or emotional reciprocity, and lack of spoken language.
In light of the above information, the following recommendations were made:
I . Developmental: Calvin should continue services through Early Intervention to address his developmental delay.
2. Psychological: Services appropriate for children with mild-to-moderate autism would be beneficial for Calvin. Calvin's parents may benefit from information available through the Autism Society. Early Intervention Preschool and Early Childhood Special Education Services are recommended for Calvin. In order to promote social interaction with peers, supervised "play dates" with same aged children are recommended. Stanley Greenspan's book The Challenging Child and "floor time" techniques of play may be of special interest to Calvin's parents and greatly beneficial for Calvin Referrals for services in the Corvallis area include: Psychologist: Kimberly Wolk Golletz (541) 758-1556; Psychiatrist: Rebecca Gordon, (541) 757-5235. Mr. and Mrs. Harris are advised to consult their pediatrician for other professionals in their area.
3. Speech/Language Pathology: Continued Early Intervention Services and special services for language impaired children are recommended for Calvin. Reading books together and playing with Calvin were recommended to enhance language development.
4. Calvin would benefit with a follow-up assessment in approximately one year and before entry into kindergarten in order to inform educational programming and support services.
Thank you for the opportunity to meet with Calvin and his parents today. If you would like any further information regarding this report, or have any questions, please do not hesitate to contact us at (503)494-2749.
Laurel Robertson, M.A.
Psychology Intern
Cynthia M. Hartung, Ph.D.
Clinical Psychology Resident
Darryn Sikora, Ph.D.
Psychologist
03/15/99 T: 03/15/99
3.2
Oregon Health Sciences University
Consultative Report
CHILD DEVELOPMENT AND REHABILITATION CENTER
P.O. Box 574, Portland OR 97207-0574
Name Harris, Calvin
Birthdate 02/22/1996
Account No.
Medical Record No. 01-44-75-05
CLINIC DATE: 03/11/1999
CLINIC NAME: EARLY CHILDHOOD ASSESSMENT TEAM CLINIC
DISCIPLINE: SPEECH/LANGUAGE PATHOLOGY
Calvin, a three-year-old male was seen today on the referral of mother for concerns of development and behavior. Primary care physician is James Nusrala, M.D., from Benton County. Currently, Calvin is involved in an Early Intervention Program that he receives services through his Kindercare program. He is seen by an Early Childhood specialist one time each week, by a speech/language pathologist four times a month, and receives autism services every other Friday.
Birth was reported to be unremarkable, with the child weighing nine pounds, three ounces. By report, he has been a healthy child and began walking at 13 months, with the use of first words delayed at around two years of age. Gross motor milestones were reported to be within normal limits.
HEARING: Hearing was evaluated by Audiology today and found to be within normal limits. Please see the report from this date for further information.
SPEECH AND LANGUAGE EVALUATION:
Behavior: Behaviors observed today included poor eye contact, limited play, perseveration, hand-flapping, and lack of interest in people.
Oral Motor Function: Peripheral observation revealed oral structures to be within normal limits. Feeding issues of overstuffing are present. This child does not choke or gag on food nor is he reported to demonstrate any difficulty with different textures of food. He is reported to hold his food in his mouth with his hand at times from the overstuffing.
Articulation: Articulation assessment was not completed today due to time constraints. Complete assessment would be appropriate when Calvin reaches the age of four years.
Language: To assess both receptive and expressive language development, the Preschool Language Scale - III was administered. Calvin obtained an auditory comprehension standard score of 62, placing him with an age equivalent of 17 months. Today he was reported to follow simple directions, such as "get your socks". He identified objects and pictures, indicated body parts on himself, and is reported to put toys away upon request. He did not demonstrate understanding of verbs in context, spatial concepts (in, out of, and off), or pronouns (you and him/her).
Expressively, he obtained a standard score of 72, placing him with an age equivalent of 23 months. Words he was heard to say today include "toys", "clock", "okay", "no", "eye", "ear", "shoe", sock", "hat", nose", and "eat". He will name objects, uses one pronoun, and he also uses plural forms. He did not answer "what", "yes/no", or "when" questions today or produce four to five sentences, which would be appropriate for a child of his age.
IMPRESSION: A language disorder secondary to autism is present.
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ORIGINAL-MEDICAL RECORD
CLINIC DATE: 03/11/1999 Med Rec No.: 0144-75-05
Page 2 Name: Harris, Calvin
RECOMMENDATIONS:
It was a pleasure to see this family today. Team members would be available for a consultation with this family upon their request.
Kathryn De Armond, M.S., C.C.C.
Speech/Language Pathologist
(503) 494-4024
D: 03/16/99 T: 03/17/99
cc: TIM AND KATHY HARRIS
Oregon Health Sciences University
Consultative Report
CHILD DEVELOPMENT AND REHABILITATION CENTER
P.O. Box 574, Portland OR 97207-0574
Name Harris, Calvin
Birthdate 02/22/1996
Account No.
Medical Record No. 01-44-75-05
CLINIC DATE: 03/11/1999
CLINIC NAME: EARLY CHILDHOOD ASSESSMENT TEAM CLINIC
DISCIPLINE: PEDIATRICS
Calvin is a three-year-old boy who is referred here by his parents and Dr. James Nusrala for further evaluation of his developmental delay. He has been diagnosed by educational criteria as having autism. The parents are interested in further looking at this diagnosis to see if it is correct and also obtaining help in knowing how to help Calvin meet his full potential.
Calvin was the product of a second pregnancy with delivery at Good Samaritan Hospital in Corvallis, Oregon at 42 weeks gestation. Mrs. Harris remembers no difficulties with her pregnancy. She had had one prior miscarriage. Birth weight was 9 pounds, 3 ounces. Delivery was vaginal with a vertex presentation. Mrs. Harris remembers some problem with slight jaundice and the use of antibiotics briefly for possibly increased white blood cell count or bacteria. Actual medical records are not available to us today. Mother and child went home at three days of age. Mother breast-fed Calvin and remembers no difficulties at all during the five and one-half months that she did this.
Calvin is followed by Dr. James Nusrala. He presently is taking B 6, magnesium and B 15, prescribed by his father since his diagnosis of autism in January. He has no known allergies. His immunizations are reported up-to-date. There are no concerns about his vision and no concerns about his hearing. He apparently has been treated previously because of the concerns with speech delay. He has had problems with otitis media and colds but no re-hospitalizations and no other significant illnesses. There is no history of seizures.
Mrs. Harris reports no real difficulties around meals or eating. Calvin has no problem with choking, gagging or drooling at this time. However, she notes that he does frequently stuff his mouth with food, often using his hands when she is not looking. He can, however, eat with utensils. He did have some regurgitation and some vomiting up until six months of age but that is no longer a problem. He has no problem with constipation or diarrhea.
Calvin has been sleeping in his own bed since two and one-half years of age. However, after an illness in late 1998 when he did sleep with his parents, he now frequently wants to come into their bed in the middle of the night. Otherwise there are no concerns with his sleep and he does take a nap through his daycare.
Developmental gross motor milestones are reported to be normal. Calvin is reported to have sat at six months of age, crawled at seven months, and walked at 13 months. Ks first words, however, were delayed until at least two years of age, and his mother reports that presently he mainly uses single words at home, although he apparently does at times use two-word or three-word phrases in other situations. He has been attending Kindercare on the OHSU campus since two years of age. Mrs. Harris reports that it was there that he first concern was raised about his speech and that she had no concerns before this time. He was evaluated by Early Intervention in June of 1998 and began going to a speech group one time per week. Concerns were later raised about possible further difficulties.
3.2
ORIGINAL-MEDICAL RECORD
CLINIC DATE: 03/11/1999 Med Rec No.: 01-44-75-05
Page 2 Name: Harris, Calvin
In December of 1998, he was again evaluated by Early Intervention and diagnosed as educationally autistic. Since February of this year, he has been receiving help from the Regional Program for Autistic Program, apparently every other week in his daycare program.
Family history is unremarkable.
Mr. and Mrs. Harris note that Calvin tends to be peripheral in his interaction with other children and that the daycare has raised concerns about his lack of interaction with other children. He does have difficulty with safety issues, and Mother most recently has tried to resort to spanking to keep him from running into the street. She notes that she does have to keep A close supervision with regard to his whereabouts unless he happens to be watching television. In the past, he has done some toewalking and he does have some repetitive motion of one hand while he is sucking the thumb of the other hand.
PHYSICAL EXAMINATION: Height 96.2 cm (less than the 50th percentile). Weight 15.4 kg (75th percentile). Head circumference 51.5 cm (greater than the 50th percentile). Calvin was very tired during my interview and assessment with the family. He returned from his speech testing and immediately started crying when his father would not let him leave the room. He then stumbled over a table and cried loudly for a few minutes before calming down and immediately falling asleep. General physical examination was not attempted today. He has no dysmorphic features. My observation of his gait and performance in other examining situations was that he has norm,-4motor movement and probably normal tone. In my brief encounter with him, he did have poor eye contact but he was very tired. I do not feel I had a good assessment of his interactive skills from today's evaluation.
DIAGNOSES:
1) Language disorder.
2) Speech delay.
3) Fine motor delay
4) Behavior Disorder, not otherwise specified.
My direct history from the parents does not allow me to confirm a medical diagnosis of autism. Unfortunately, I was unable to see Calvin in his normal state. The other members of the team, who dealt with Calvin earlier in the morning, felt that he did meet speech, social, and repetitive movement medical criteria for a diagnosis of autism. Please see the Case Coordinator's Summary for full team evaluation and recommendations.
Patricia Garliger, M.D.
Developmental Pediatrician
D: 03/11/99 T: 03/11/99
Oregon Health Sciences University
Consultative Report
CHILD DEVELOPMENT AND REHABILITATION CENTER
P.O. Box 574, Portland OR 97207-0574
Name Harris, Calvin
Birthdate 02/22/1996
Account No.
Medical Record No. 01-44-75-05
CLINIC DATE: 03/11/1999
CLINIC NAME: EARLY CHILDHOOD ASSESSMENT TEAM CLINIC
DISCIPLINE: PEDIATRIC AUDIOLOGY
DATE OF BIRTH: 02/22/96
AUDITORY FINDINGS: Calvin was assessed within a sound-treated environment using visually reinforced audiometrics. He conditioned well.
For speech stimuli, responses were 15 decibels HL across several trials with good localization. He performed similarly well to narrow bands of energy centered at 3,000 and 6,000 hertz, with responses down to 25 to 30 decibels HL.
Middle ears were assessed using pneumatic otoscopy. The ear canals were clear. The eardrums were quite mobile to pneumatic. There was no evidence of drainage or infection.
DIAGNOSTIC IMPRESSION: Normal hearing bilaterally.
COMMENTS AND RECOMMENDATIONS: It is clear from the auditory results that Calvin has hearing levels well within the normal range and adequate for communicative and cognitive needs. Presently, there are no ear or hearing-related issues. The findings were shared with the parents and with the clinic team. There are no present ear or hearing-related recommendations.
Pediatric Audiology
D: 03/11/99 T: 03/11/99
3.2
ORIGINAL-MEDICAL RECORD