Case for Risk & Protective: Joey

Joey is a 4-year-old child presenting for evaluation.

Joey was born at 39 weeks by means of a planned cesarean section. His parents reported that was

colicky as an infant but he did not experience sleep or eating disturbance. His parents first became

concerned with his development at 13 months because he wasn't starting to develop words yet.

Family History

Joey's mother had some learning disabilities as a child. He has a maternal aunt with autism.

Social History

Joey lives with his mother, father and older sister Kylie (7). His parents are US citizens, but they

immigrated from Uganda before their children were born. Both his parents work as pilots for a

major airline. They often work opposite schedules, but may need to sleep during the day due to

shift work. Joey's grandparents all live close by and when he is not with his parents, he is with

one or the other set of grandparents. He is currently not in any school settings, as when they tried

the preschool his sister went to they indicated that they could not support him at this time due to

his high activity level and physicalness with other children.

Parent Report

In regards to communication skills, Joey will often sign the word “more” when he wants more. He

will also bring things to his parents or will bring his parents to what he wants. He will use some

words to express his wants and needs. For example, he will say “help” or “milk” or “potty”. His

expressive language usually involves two word phrases. Occasionally he will use three to four

words. Receptively, his parents reported he responds to requests and smiles when hearing praise.

Joey is labeling objects and making requests. He is sometimes able to answer questions such as

“what would you like to eat?” He has started to ask questions, but this is a new ability for him.

His parents noted that he does a lot of imitation and will regularly repeat some things. His mother

noted he also displays delayed imitation.

Joey does not consistently respond to his name and his parents often need to use a should tap

prompt to get his attention. Joey follows familiar directions, but will often ignore new requests.

For example, his parents recently asked him to hold his father's pocket when he crossed the street

and he tried to take his hand instead. He became distraught when he could not take his hand

because his father had bags in them. Joey does exhibit some difficulties with articulating p's and

b's. His parents can understand him, but others cannot. His parents noted that he does interpret

nonverbal cues well and can tell when people are mad.

Joey tends to be very active. It is hard for him to sit down and play. He quickly moves from activity

to activity. His parents reported that transitions and changes have been difficult in the past for

Joey. His father stated that they usually have to pick him up for him to transition. Joey will get

behaviorally dysregulated about half the time when asked to transition. He will kick, scream and

flail when upset. His tantrums last about 1 minutes, but can be shorter if his parents distract him.

Joey has a history of lining up his toys and he will look closely at parts of some of the toys he

plays with. Joey has opportunities to engage with children his age. He engages in parallel play

with his peers. If he does engage in play with other children they will disengage because he gets

too physical. Joey is drawn to cars and balls, but does not use them in pretend play.

In regards to sensory issues, he does not like tags in clothing. No other sensory issues were

reported.

Observations

Joey arrived for the evaluation with his mother and father looking his stated age and comfortably

dressed. He separated appropriately from his parents to join the evaluator in an additional testing

room. Throughout the testing session, Joey demonstrated a distractible attention span and a high

large motor activity level for age. His affect was appropriate to context.

During the testing session, Joey showed some nice skills, as well as some areas of concern when

compared with other children his age. In the area of language and communication, Joey

demonstrated delay as well as disorder. He spoke mostly in single words, with a few two-word

phrases. He also made many word approximations. Joey engaged in babbling and sing-songy

expression throughout. Repetitive noises were observed almost constantly during the testing

session. He also frequently said phrases such as “go-go” and “all done”. These phrases did not

seem consistent with his behavior and mostly used in a repetitive manner. Receptively, he required

multiple prompts and would not turn toward the evaluator when his name was called.

Socially, Joey showed variable skills. He pointed and showed nice affect, often smiling and

giggling at the examiner. Joey's eye contact was variable throughout the testing session. He, at

times, showed enjoyment in interactions with the examiner, such as playing catch with the

examiner. When engaged in this exchange, maintained the interaction, but would not initiate it.

However, if the examiner tried to change this exchange in any way, Joey would screech until the

pattern started again. Other reciprocity was limited. Throughout, interactions he tended to be on

his own.

In the area of play, Joey showed an interest in cars and animals, but he did not demonstrate pretend

play with these items. He mostly would carry them or look at them. He also showed some repetitive

play when engaged with the cars, showing an interest spinning the wheels over and over while

holding them close to his face.

During the evaluation, Joey did well with transitioning into the testing room. However, he had

more difficulty transitioning between activities within the testing session. He would become

fixated on certain toys and would become upset if these were taken away from him. During the

testing, it was hard to gain Joey's attention and he engaged in a lot of movement.

Strengths seen in Joey during the testing session include his enjoyment in some social exchange

and self-advocacy. When he was observed with his parents he would climb into their laps and pat

their hands. He also had an infectious smile and could engage others briefly with eye contact.