Case Study: Oscar

By Jennifer Everett, OTR

I have been practicing OT for almost 25 years of which at least 20 of those years have been in pediatrics. I have attended many conferences/courses over the years. This course by far has been the most beneficial. It is the only course I have attended that some part can be applied to every student/client on my caseload.

Oscar is a 48-month-old boy who is in the process of being adopted into the family he had been with since he was 11 days old. There are two siblings in the home; one is a half sister who is 7 years (adopted into this home due to abuse by Oscar’s mother) and a brother who is 2 ½ years old. Baby sister is 4 weeks old. I will call his adoptive parents Mom and Dad as that is what they are and what he calls them.
Prenatal history: A lot is unknown. His birthmother was pregnant with Oscar when she abused his half-sister and while awaiting trial for the abuse charges. Oscar was to be relinquished to the state at birth. It is believed his mother did some meth and other drugs until the 4th prenatal month at which time the state started testing her weekly. It is known that she has problems controlling anger and is verbally and physically abusive to others. His biological father also used meth and has problems with self-esteem. So, we know during prenatal period, besides drug exposure, Oscar was in a “hostile “ environment with a lot of stress. He was a C-section baby and was bottle-fed.

Medical history: hospitalization for RSV at 6 weeks with continued asthma problems with upper respirator infections since then; three febrile seizures in two days at 12 months, none since; multiple ear infections with tubes placed at 18 months and removed at 3 years.

Mom believes Oscar met milestones on time. She cannot remember much about belly crawling or crawling, but he did not do much of this and learned to walk just as he turned 10 months old. He also talked early using vocabulary by 18 months that “surprised” people. He never liked to cuddle, had poor eye contact and was a very poor sleeper. He has always liked to chew non-food items including diaper lining, hair or fuzz from stuffed animals, hair from cats or dogs, crayons, etc. He wants to feel everything and especially likes to rub it on his face. He often has crayon or marker on his face. He used to smell everything, but became sensitive to smell at 3 and a half, frequently gagging due to smells. He uses noise-cancelling headphones and has extreme fear of going into public bathrooms without them. He also uses the headphones at zoos, when vacuum is on, and when Dad mows the yard (even if he is in the house).

Oscar frequently does not respond to name being called. He has hearing tested by audiologist with normal results.

Oscar has had social difficulty since age 1 when he was moved into a new room at daycare. Mom knows he was bit multiple times over the first 7 days in the new room and then he started biting, hitting, and shoving which has continued. In defense of Mom, she was not told of the biting until Oscar was being kicked out of this day care at age 3 and they reviewed his records with Mom. After two months at home, Oscar was placed in a half-day preschool but was removed after 5 days because he would ride the tricycle too fast, push others when playing chase, and would not “calm down”. Oscar was also aggressive with siblings at home and would shove or bite if they were near him- especially if siblings were moving quickly near him. He would say he did not know why he did this and seem upset with himself for a few minutes, but could not stop himself from the hitting and biting. He also liked to sit near Mom or Dad and feel their arm, then squeeze or scratch it. He was tense and anxious in public situations like parks, zoos, libraries, and stores and might bolt or have meltdowns. So Mom hesitates to take him many places. However, this same child could walk in the woods and by the lake for an hour telling stories, talking about the snails and animals, and stopping others walking with him so they would not scare a rabbit, turtle. He would listen to very detailed books on tape or read to him for at least 20 minutes at a time, but only had a 1 to 2 minute attention span for play dough, trucks, helping with chores, or even helping with mixing treats. He could add and subtract up to 5 in his head, knew numbers, letters, and sounds of letters. Everyone who meets him says, “He is so smart”. Mom knows he is “smart”, but he will have a difficult life if he cannot not get his emotions under control and enjoy life and learning more.

At 3 years 6 months, Oscar saw an OT who specializes in sensory processing disorder. He was diagnosed with Sensory Processing Disorder: Under responsive vestibular system with post rotary nystagmus of 0 seconds, Oral sensory seeker, delayed fine motor, retained ATNR and STNR. The OT had Mom do heavy work or activity every 2 hours at home. Oscar went to 2 months of weekly one-hour therapy sessions – each week behavior became worse at therapy and home. Mom stated that at therapy, Oscar was tense and “on-guard”. Therapies usually involved running, jumping, wiggling through tunnel with weighted toys then fine motor skills. Oscar would do a short amount of an activity- then try to run and hide. If mom or therapist grabbed his hand to bring him back, he would pull the hand to his mouth and bite. The running and jumping activities really made things worse quickly. It was decided that OT was not productive and it was stopped. At this point, Mom who is an educator (1st grade) was becoming very worried about how to help Oscar. She made an appointment with a behavior specialist and started researching more about sensory processing and problems with this. Move, Play, Thrive information was on the Special-ism website and Mom was interested in the Primitive Reflex Integration. Mom knew contacted me, as I am school therapist and asked if I knew anything about the course. I didn’t but after research the course felt like it would help my students so I offered to take the course and work with Oscar in the process.

Since I had just started this [Brain and Sensory Foundations] course when I first started working with Oscar, I tested his reflexes in the order of the video presentations. Oscar tested positive for TLR, ATNR, STNR, Babkin, Babinski, Fear Paralysis, Moro, and Spinal Galant.

At first, Oscar really resisted the brain tune up so just Rhythmic Movements were started and done daily by Mom for two weeks. Oscar really liked these when done to nursery rhymes and if there was a promise to tickle tummy after them. He tolerated 10 to 15 minutes of the exercises from the beginning, but when tickled he would grab and pinch or pull the tickling hand to his mouth to bite, yet he would request more tickling.

After two weeks, I tried the brain tune up again with Oscar. He still resisted, so TLR, ATNR, and STNR integration were added in the form of “play” as he could not participate in isometric integration. Balloon toss, pretending to be a puppy or kitty, crawling and looking side to side and up and down were some of the activities during therapy. He also liked to hold stuffed animal under chin and crawl to put it in a basket.

At the one month point Oscar was becoming dizzy when spinning on a disk swing or twirling himself. This was a new sensation for him. Mom was seeing short periods (5-8 minutes) where Oscar could play with siblings without pushing or biting. He still could not play on slides or climbing toys without immediately shoving anyone who got close to him. I started him on the fear paralysis tapping and the Moro rolly polly. Mom was also able to find a pre-school for him two mornings a week run by a speech therapist with a physical therapist on staff. There are only 3 children in his class, so they are able to work closely with each child.

After two months, Oscar was able to do ATNR integration lying on his back looking at stuffed animals and switching so this was added alternating days along with palmar and plantar integration. He now would do the brain tune up with assistance prior to exercise. His biting had decreased, but he still bit if face was touched or hand was grabbed. I decided to test his rooting reflex and found the left side of his face was ticklish and the right side stroking caused an immediate head turn toward right and biting action. So, rooting reflex integration was added, as the biting was a big social problem for Oscar. I did learn during this process it is wise to use something other than your finger for testing for rooting reflex! I could also see how closely linked the hand/feet/mouth reflexes were related while working with this child.

Two and a half months into the exercises, Oscar was much better with siblings with very few episodes of pushing or hitting and no unprovoked episodes of aggression. Biting had greatly decreased only two times in two weeks and both times he was overly excited. He no longer chewed on non-food items, but chewed gum daily. He still had trouble getting to sleep and would wake once in the night to go to the bathroom, but would go right back to sleep which was a big improvement

At this point the spinal gallant reflex was integrated, but we continued to work on it to be sure. The Palmar/Babkin and Planter reflexes were much improved, but still mildly present. ATNR was still present, but so much better and Oscar could track across midline with eyes both directions. STNR also was improved and he tilts head back for hair washing with eyes closed without problems.

Now three months into working with Oscar, Mom reports she is able to take Oscar more places without as much fear of his aggressive behavior. He is able to play about 20 minutes with others before he becomes too “wound up” and needs a break to calm down. He is still anxious in new settings and does not like crowded rooms. Preschool reports most days are good with only 1 or 2 time outs, but he can still be too aggressive with other children. We will continue working on all the reflexes and daily rhythmic movements along with daily bear hugs and tapping.

Mostly through this experience I have reaffirmed the need to be flexible and allow your client to be your guide. Take your cues from our client and modify exercises/activities based on there needs, comfort level, and interests while keeping the outcome of treatment in mind.