Case in Progress

Salvador- Progress

Salvador was born on November 25, 1997, at 24.5 weeks gestation. His myriad of health problems associated with his prematurity included respiratory distress syndrome, broncho pulmonary dysplasia, patent ductus arteriosis, retinopathy of prematurity, sleep apnea, nasal cannula for oxygen, failed newborn hearing screen, irritability, and increased extension tone

Salvador was discharged on March 6, 1998, at the age of 101 days. He went home with several life-saving pieces of equipment, including a nasal cannula for oxygen, a sleep apnea monitor, several medications. His family also had scheduled follow up appointments with a home health nurse, ophthalmologist, California Children's Services, and the local regional center for early intervention services. Even with all this his parents were very relieved and happy to be going home.

Salvador was first seen by a regional center worker one week after he arrived home. It was apparent that he and his parents would benefit from early intervention services. When he was first assessed at the age of 4 weeks (corrected age) he weighed 7 pounds, 12 ounces. His skills clustered around his age of 4 weeks at this time

Salvador was assessed for his first birthday, and it was great to see how much progress he had made in the past year. His corrected age was nine months (36 weeks) at this point.

His skills were as follows:

• Gross Motor - 30 weeks, Salvador could crawl, sit alone, and stand holding on to something. Cognitive was solid at 30 weeks - Salvador could remove a cube from a cup, overcome an obstacle to get a toy, and play with a variety of toys.
• Fine Motor was solid at 36 weeks - he would investigate a toy or object with his fingers and used an inferior pincer grasp.
• Visual Perceptual Skills were at 36 weeks - with corrective lenses, Salvador was able to look toward an object, direct his reach, and adjust as necessary.
• Self-Care was at 36 weeks - Salvador was able to hold his own bottle, eat mashed table foods, and chew with a rotary motion.
• Communication was at 24 weeks - and his hearing had an impact here.
• Socially and emotionally Salvador was at 30 weeks, and he would explore familiar faces, respond differently to adults and children, and enjoyed his play in the bath.

While these skills levels represented global delays for Salvador, it was encouraging to see the gains he had achieved, despite his very rough start in life. It was determined that physical therapy and an educational specialist would continue to provide intervention to address all areas of his development.

In late January it was noted that Salvador scissored his legs when in an upright position. This crossing of his legs would impede his progress in learning the mobility skill of walking. At this time he was accepted at California Childrens Services for an evaluation due to his extreme birth history.

In late February we received the disturbing news that Salvador was hospitalized for RSV. This was the virus that we had requested he receive a vaccination for, and his pediatrician had refused. He was placed on a respirator for a week, and was discharged, weak and exhausted, as was his family. Salvador began to see a pediatric pulmonologist, who had several recommendations that were done immediately, such as using prescribed inhalors, stop the bottle so that he would not aspirate milk, use HEPA vacuum cleaner bags and dust mite free mattress.

It took all of March for Salvador to recover from his illness, and he was hospitalized again overnight in April and again in May. His parents were exhausted from fear and not enough sleep.

One of the areas that had been left behind during this period of illness was Salvador's hearing aids. Due to issues with MediCal insurance procedures, they had still not arrived. He finally received them, and would tolerate them periodically (he tolerated his glasses only marginally better). We strongly encouraged his parents to make him wear these appliances, and to follow the pulmonologists directions.

We began having an occupational therapist work with Salvador in addition to cognitive and physical therapy. The occupational therapist worked with Salvador and his mother on feeding and using his fingers correctly when playing with and picking up toys. By August it was decided that Salvador had made enough progress physically and would need only cognitive and speech therapy. He had begun to walk independently and was doing well in that regard. CCS graduated him, as he was doing so well physically.

The family had moved to a new home, and as it was warmer, there seemed to be more of a chance for Salvador to remain healthy.

Our biggest concern at this point, other than Salvador's health and his speech, was his behavior. He had always been an irritable child, with difficulty making transitions. He much preferred to do what he wanted to do. His parents tended to let him do exactly that. There were many reasons, not the least because it was easier and they were exhausted, and because he had been so ill so many times. However, he was beginning to throw objects and to hit, especially at his mother. It was decided to work closely on his speech development, in the hopes of lessening his frustration, while working on cognitive development.

Salvador at this point was refusing to wear his hearing aides and throwing his glasses off whenever he was angry or frustrated. We worked with him and his assistive devices for longer and longer periods of time, with success varying from week to week. His health at this time was much better. We started working with family on discipline methods, which seemed to be going well.

At Salvador's second birthday he was assessed and found to be functioning at the following levels:

• Fine motor - solid at 12 months. Salvador could put a large round peg in a board, remove the cover of a small box, and grasp two small objects with one hand.
• Cognitive development - solid at 14 months. Salvador would find a toy after it had been covered three times, get a toy out of a container after it had been dropped through a hole in the top, and release nine cubes into a cup.
• Social/emotional - solid at 14 months. Salvador would initiate ball play, imitate an activity's function, and make choices in toys and food.
• Self-help skills were at 13 months - Salvador had ceased drooling and could drink from a cup, and his Gross Motor skills were at 18 months, his biggest strength. Salvador could walk and run well, climb onto adult furniture, and climb one step.
• Salvador's receptive language was at 14 months and his expressive language was at 11 months.

Due to his levels at this time we began to surmise that he might not catch up to other children his age, and that he would possibly need a special day class setting when he turned three.

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