Levin 1

Kylie Levin

May 8, 2017

Culminating Project

Noah is a 13-month old boy, adjusted at 9-months old. He was born at 25 weeks and

spent about 3 months in the NICU after birth. It was suspected that Noah was drug

exposed and did not receive sufficient prenatal care. From the hospital, Noah went into

foster care and about 3 months later moved in with his aunt. He only lived with her for 4

months until he moved in with his cousin Kathy, which is where he currently resides.

Kathy is fostering Noahs younger brother Tommy (3 months, 0 months adjusted) and

also has an adopted 10-year old daughter in the home. She hopes to adopt Noah and is

unsure if she can care for Tommy long-term, as he is showing delays as well. The three

tools we used to assess Noah were the McWilliams Routines Based Interview (RBI) and

Ecomap, Bayley Scales of Infant and Toddler Development: Third Edition (Bayley), and

the Hawaii Early Learning Profile (HELP). The Bayley and Routines Based Interview

were completed at his aunts home back in October. His IFSP has been updated since he

moved to Kathys, including a change of routines and changing the outcome statement.

Noah recently underwent 4 small surgeries at once including a circumcision surgery, two

eye correcting surgeries, and a stomach surgery.

The RBI and Ecomap were completed during the initial intake with his aunt, but

the RBI was reviewed and updated once he made the move to Kathys house, he was 10-

months old (6-months adjusted). The RBI provided specific details on Noahs day-to-day

schedule like bath time, diapering, mealtimes, play, getting around the house/community,
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and spending time with others. The interview allowed Kathy to express her concerns in

the play, mealtime, and toileting routines. He was crying consistently while having bowel

movements and would take 20-25 minutes to drink a bottle of formula. This was

corrected during surgery when the doctor discovered Noah had a bowel obstruction

(twisting of the intestines). She stated that Noah is bringing rattles to his mouth and is

putting his feet in his mouth and he has emerging skills in lifting his head when is he on

his belly. She has noticed that Noah will hit himself in the head with his hand or bang it

with a toy. After collecting the details from the RBI, the service coordinator,

developmental specialist, and Kathy came together at the IFSP review and based an

outcome statement off of Kathys areas of concern and the developmental level Noah was

currently at. The listed outcome on the IFSP reads, During playtime Noah will be sitting

up and playing with toys. Although Kathy was familiar with the Bayley results, she

could see delays in his motor development and that it was affecting his play routine. The

RBI provided us with sufficient information. The Ecomap was not updated when Noah

moved to Kathys, so more information on informal supports would be beneficial to the

professionals.

The Bayley assessment was completed when Noah was 7-months old (adjusted

for 3 months). It was administered after the initial intake with his aunt, service

coordinator, and developmental specialist. It compared Noahs scores in the cognitive,

language, motor, social-emotional, and adaptive behavior domains to the average child

his age. The results of the Bayley would determine if he was eligible for early

intervention services. They used standardized toys and tools to prompt Noah to carry out

age appropriate tasks. The results of Noahs Bayley are as follows:

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Subset Total Raw Score Percentile Rank Scale Score Composite

Cognitive 12 25 8 90

Language 5- Receptive 34 6- R 94
7- Expressive 12- E

Motor 7- Fine 1 7- F 67
4- Gross 2- G

Social-Emotional 52 91 14 120

Adaptive Behavior 55 27 Sum- 64 91

The composite score for the cognitive domain indicates Noah performed within the

average range. He was able to recognize his caregiver, show visual preference with a

striped pattern on a book page, and decreased his attention to a picture within 30 seconds.

The composite score for the language domain indicates Noah performed within the

average range. In the receptive category, he appeared to fixate his gaze on a person for at

least 2 seconds, calm down once he was spoken to, and clearly respond to a persons

voice. In the expressive category, Noah smiled in response to a speaker, vocalized two

different vowel sounds (eg. ooo, ahh), and tried to get the attention from an adult in the

room. The composite score for the motor domain indicates Noah performed in the

extremely low range. In the fine motor category, he was able to follow a moving person

and hold a ring for at least 2 seconds. In the gross motor category, he thrust his arms and

legs several times and lifted his head upright for at least 3 seconds without support. This

specific subtest was the reason he qualified for early intervention services. Noahs aunt

rated him as superior in the social-emotional domain. The only task he had not display

were showing interest in being swung around or lifted in the air. Her answers in the

adaptive behavior domain scored in the average range. A decent portion of this scale did
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not apply to him due to his age. I believe there is missing information for the social-

emotional and adaptive behavior subsets. Since his aunt filled the booklet out on her own,

I think a conversation is needed to analyze why she answered the questions the way she

did. I think digging deeper into each category will not only benefit the early intervention

professionals, but it would reassure his aunt that his current level of development does

not call for him to always carry out every task listed in the booklet.

The HELP was filled out with Kathy recently when Noah was 13-months old. The

skills and behaviors that were looked at were for his adjusted age of 9 months, so only a

portion of the questions was answered. He appeared to be within normal range for a

majority of the cognitive strand items, but he seemed to show emerging skills in the items

that entailed motor abilities. Out of the 45 age appropriate cognitive skills on the HELP,

Noah is performing 20 of them already. Due to his young age, there were not as many

language strand items to measure. His receptive language has not yet been observed, if

not emerging. For the assessment item Responds to simple requests with gestures, he

has not yet done this because of his motor delays. Noahs expressive language would be

considered below normal range. He is starting to say b and m sounds, but is not yet

connecting a vowel to a consonant. Out of the 32 language items on the HELP, he is

performing 11 of them already. Noah has recently been displaying a lot of growth in the

gross motor strand. We were pushing Noah to roll over, and now he has begun rolling

across the floor in both directions on his own. His arm used to get stuck beneath him

when he was in the prone position, but now he is capable of fixing his arm by pulling it

from underneath. Although he has made so much progress, Kathy still has concerns of his

development. She would like to see Noah sit up and play with his toys independently. We
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have practiced bearing weight on his hands for several visits now and have encouraged

Kathy to practice sitting with Noah with the support of a boppy pillow. Of the 64 relevant

gross motor items for a 9-month old, Noah is currently only able to complete 22 of them.

Noahs fine motor skills appear to be in the normal range, with some skills and behaviors

still emerging. For some of the items like the reach/approach category, he is not fully

capable in completing the tasks due to his motor delays. Kathy reported that he is holding

his bottle with both hands as long as she supports him at first. Noah is currently able to

complete 31 of the 51 fine motor tasks. Based on the results, he appeared to be within

normal range for the social-emotional strand items. Since Noah has lived in three

different homes, it has taken some time for him to warm up to Kathy. Every time we go

over for a visit, he seems more and more attached and lights up when shes around him.

Some of the social interactions and play items have not yet been met because of his

motor delays. Out of the 49 social-emotional items on the HELP, Noah is performing 30

of them already. In the self-help category, Noah is not yet feeding himself let alone eating

solids, so a number of the skills have not been achieved or observed. He is still given a

bottle, but has been drinking it faster since Kathy changed his formula. He is currently

performing 12 of the 28 self-help items that apply to a 9-month old. As of now, Noah

enjoys when he is touched and handled, stays awake for long periods of time without

crying, and listens to speech even if there are distracting sounds in the environment. For

the 20 relevant items in the regulatory/sensory organization strand, Noah can complete 12

of them already. The results Noahs HELP we completed with Kathy are as follows:
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Strand Category Raw Score # Completed

Cognitive (+) 20 (+/-) 10 (-) 15 45/93

Language (+) 11 (+/-) 7 (-) 14 32/129

Receptive
Expressive
Gross Motor (+) 22 (+/-) 10 64/151
(-) 27 (N/A) 5
Fine Motor (+) 31 (+/-) 9 51/104
(-) 10 (N/A) 1
Social-Emotional (+) 30 (+/-) 12 (-) 7 49/113

Self-Help (+) 12 (+/-) 6 (-) 10 28/95

Regulatory/Sensory (+) 12 (+/-) 1 20/32

Organization (-) 4 (N/A) 3

The items on the Bayley and the HELP overlapped quite a bit. The subsets or

strands cover the same domains and are organized by developmental sequence. Although

the Bayley was administered six months before the HELP, there were some evident

trends found in both assessment results. The cognitive domain in both assessments

revealed that Noah would intently look at pictures, react to a disappearing face or object,

and turn his head to explore his surroundings. The gross motor domain in both

assessments determined that he could extend his legs and arms during play and lift and

hold his head for at least 3 seconds, if not more. I found some alignment in the social-

emotional and self-help domains as well. Noah will respond with a smile and is soothed

by his caregivers voice, will cry if he is upset or hungry, and will look at anyone when

they are talking. It was interesting to see the similarities in the responses of Noahs aunt

and Kathy in the social-emotional and adaptive domains on the Bayley and the HELP.

Some responses were a bit different, but this could have something to do with timing of

assessment.
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After sorting through Noahs assessment results and knowing what I know from

talking with Kathy, it can be concluded that his tier one needs involve coaching her on

some strategies that work at his fine motor skills. This might look like asking Kathy if

she has tried anything so far, suggesting she think of a few ways she could incorporate

fine motor exercises into their daily routines, and then allowing her to practice with

reflective feedback. If Kathy were not able to think of ideas, I would mention placing

items (whether its food or a toy) where he can reach to encourage practicing his grasp.

Kathy would need to start with larger items and then introduce smaller items as his

capacity grows to hone in on refining his fine motor skills. Noahs tier two needs include

discussing and suggesting strategies to practice around the house to work on his receptive

language skills. Kathy could find items around her house that produce various sounds that

might catch Noahs attention. She may have to think about this need a little more, as he

was not able to search for the source of a sound during the Bayley administration. As of

recently, he seems to selectively listen to others or sounds in the environment, so if Kathy

is the one making or creating the sound (since he is now recognizing her voice and

looking around the room when hes in his bouncer) it might have a more powerful effect

than the doorbell or television. These strategies might seem unusual or inappropriate to

embed into their daily routines, but if they are ever sitting around the house they could

practice receptive exercises to build his competency. Noah needs the most support for his

gross motor skills, which is why I ranked it as a tier three need. His gross motor delays

have kept him from achieving skills in other domains. This specific skill might require

more hands-on involvement from Kathy and the developmental specialist. Kathys goal

for Noah is to sit up and play with his toys. At the adjusted age of 9-months, he has
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recently proved he can maneuver around the family room by rolling in both directions. I

recommend a physical therapist comes out and completes a joint visit with the

developmental specialist, as he appears to be a very low tone and cant seem to hold his

head up in the prone position for more than 10 seconds. From the joint visit, the physical

therapist would be able to briefly evaluate his current level of gross motor development

and recommend appropriate exercises and strategies for Noah as well as suggest

equipment that might benefit him. From this visit we would like to move toward building

Kathys strengths and support her and her decisions for Noah.

Noahs Tiered Needs

Gross
motor
insight from
a physical
therapist

Receptive language
strategies and activities
to practice sound
recognition

Strategies to promote fine motor competency

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References

Maccow, G. (2008). Bayley scales of infant and toddler development-third edition.

Pearson Education. Retrieved from

http://images.pearsonclinical.com/images/PDF/Bayley-III_Webinar.pdf

McWilliam, R.A. (1992; 2009). Protocol for the routines-based interview. Baltimore,

MD: Paul H. Brookes Publishing

Warshaw, S.P. (1992-2013). HELP strands 0-3: Curriculum based assessment. VORT

Corporation.