Consent

Child's Information

• Full Name: Liam Alexander Mitchell
• Date of Birth: 14/05/2017
• Age: 7 years, 5 months
• Gender: Male
• NDIS Number: 430-892-114
• NDIS Plan Dates: 01/11/2023 to 31/10/2024
• NDIS Goals: 1. Improve gross motor skills, balance, and endurance to participate in playground activities with peers. 2. Increase independence in daily self-care routines, specifically dressing and toileting. 3. Enhance emotional regulation and communication skills in home and school environments.
• Immediate Family: Sarah Mitchell (Mother), David Mitchell (Father), Chloe Mitchell (Sister, 10 years old)

Referral Information

• Reason for Referral: NDIS plan reassessment. Functional Capacity Assessment requested to evaluate current physical, motor, and daily living skills, and to determine ongoing physiotherapy and support needs.

Diagnoses

• Primary Diagnosis: Cerebral Palsy (Spastic Diplegia, GMFCS Level II)

• Secondary Diagnosis: Autism Spectrum Disorder (Level 2)

• Paediatrician: Dr. Rebecca Vance, Perth Children's Clinic, Subiaco WA (Ph: 08 9380 4412)

• Family History of Diagnoses: Maternal cousin diagnosed with ASD; no known family hx of CP.

Medications

• Current Medications: baclofen (Lioresal®) 5 mg PO TID for lower limb spasticity; melatonin (Circadin®) 2 mg PO ON for sleep initiation.
• Medication Management: All medications crushed/dissolved and administered by parents. Kept in a locked cabinet.

Family Factors/ Informal Supports

• Family Structure: Intact nuclear family living together. Both parents share caregiving duties; older sister assists with play.
• Home Environment: Single-storey brick home. Step at front entrance (no ramp); large enclosed backyard with flat lawn. Bathroom has a standard shower-over-bath (no grab rails).
• Support Systems: Maternal grandparents live 15 mins away and provide occasional respite on weekends.
• Relevant Family Dynamics or Stressors: Father works FIFO (2 weeks on, 1 week off), placing high primary care demand on mother during on-swings, increasing maternal fatigue.
• Current Living Environment: Private rental in Joondalup WA, residing with mother, father, and sister.

Formal Supports

• General Practitioner: Dr. Michael Chen, Joondalup City Medical Group (Ph: 08 9400 1234)
• Paediatrician: Dr. Rebecca Vance, Perth Children's Clinic (Ph: 08 9380 4412)
• Specialists: Dr. Alan Grant, Paediatric Orthopaedic Surgeon, Perth Children's Hospital (Botox clinic reviews 6-monthly).
• Support Workers: NDIS support worker (Jake) 4 hrs/week (Tuesday and Thursday afternoons) for community access and physical play.
• Speech Pathology: Fortnightly 45-min sessions (Mia Lin, SP) focusing on pragmatic language and AAC use when dysregulated.
• Physiotherapy: Fortnightly 60-min sessions (Author, PT) focusing on lower limb strength, gait training, AFO compliance, and gross motor skills.
• Psychology: Monthly sessions (Dr. Emma Watson, Clinical Psychologist) focusing on emotional regulation and anxiety management.
• Equine Therapy: Weekly 45-min RDA (Riding for the Disabled) sessions on Saturdays focusing on core stability, pelvic mobility, and hip abduction.
• Music/ Art Therapy: Not currently accessing.

Early Years / Developmental History

Pregnancy and Birth

• Full-Term: Born prematurely at 31 weeks gestation.
• Complications: Twin pregnancy (loss of co-twin in utero at 20 weeks). Emergency C-section due to fetal distress. 6-week NICU admission; periventricular leukomalacia (PVL) noted on cranial ultrasound.

Developmental Milestones

• Sitting Independently: 11 months (chronological)
• Crawling: 16 months (commando crawl; did not quadruped crawl)
• Walking: 28 months with kaye walker; 36 months independently with bilateral AFOs.
• Talking (First Words): 24 months
• Noted Observations of Delays: Increased lower limb tone and scissoring posture noted by MCHN at 9 months; formal CP diagnosis made at 18 months. Social communication delays noted at 3 years.

Activities of Daily Living (ADLs)

Dressing

• Requires physical assistance for lower body dressing due to poor standing balance and LL hypertonia. Can don loose t-shirts independently while seated.
• Struggles with buttons, zippers, socks, and donning/doffing bilateral hinged AFOs (requires 100% parental assistance for AFOs).

Bathing

• Requires constant supervision and physical assistance transferring in/out of the bath over high tub wall due to fall risk.
• Washes torso and face with verbal prompts; requires physical assistance to wash lower limbs, hair, and back.

Toileting

• Daytime continent for bowel and bladder; wears pull-ups overnight.
• Requires assistance with clothing management (pulling pants up/down) and wiping due to poor dynamic standing balance. Uses a step-stool and over-toilet frame for stability.

Grooming and Hygiene

• Hair Brushing: Requires parent to brush hair due to sensory defensiveness around head/scalp.
• Teeth Brushing: Uses electric toothbrush with hand-over-hand assistance to ensure thorough cleaning.

Eating

• Eats independently using modified thick-handled fork and spoon. Uses a two-handled cup or straw bottle.
• Requires all meats and firm foods to be cut up by parents (unable to coordinate knife and fork simultaneously).

Sleep

• Sleep Hygiene/ Routine: Consistent routine starting at 19:00 (bath, story, melatonin at 19:30, lights out at 20:00).
• Bedtime/ Waking: Falls asleep by 20:30, wakes around 06:00.
• Sleep Quality: Disturbed; wakes 1–2 times nightly complaining of calf cramps/spasms, requiring parental massage and repositioning.
• Medication Compliance: Good compliance with melatonin 2 mg PO ON when mixed in yoghurt.

Ability to Handle Changes in Plans and Routines

• Response to Changes: Becomes anxious and physically rigid when routines change unexpectedly; relies heavily on visual schedules.
• Adaptability: Low adaptability to new environments; requires substantial transition warnings (10 mins, 5 mins, 2 mins) and social stories prior to unfamiliar outings.

Instrumental Activities of Daily Living

Household Chores

• Participates with high levels of verbal prompting and physical set-up.
• Can place dirty clothes into laundry basket and pack away toys into floor-level bins while seated.

Managing Personal Belongings

• Loses items frequently; requires visual checklists on school bag to remember water bottle, hat, and communication book.

Money Management

• Understands coins buy items at the canteen, but has no concept of relative monetary value.
• Requires 100% adult support for all financial transactions.

Transportation

• Unable to use public transport or navigate streets independently due to poor road safety awareness and physical fatigue over distances > 200 m.
• Transported via family car using a supportive booster seat. Uses a manual paediatric mobility stroller/wheelchair for long community outings (e.g., shopping centres, zoo).

School Performance and Participation

Performance and Engagement in the School Environment

• Classroom Behaviour and Functioning: Attends Year 1 in a mainstream primary school. Generally compliant with class rules. Fatigues rapidly by 13:00 due to increased energy expenditure from postural control and ambulation, leading to slouching and loss of focus.

• Participation and Engagement: Excluded from fast-paced physical games (e.g., chasey, soccer) at recess due to tripping hazards and reduced running speed. Prefers sandpit play.

• Additional Supports: Shared Education Assistant (EA) 0.5 FTE for physical transitions, toileting, and playground safety. Uses a sloping desk board and supportive posture chair with footrest in class.

Cognition and Communication

Executive Functioning

• Planning and Organisation: Struggles with multi-step motor planning (praxis) and task sequencing; requires tasks broken down into single steps.
• Problem-Solving: Seeks adult help immediately when encountering physical barriers (e.g., stuck zipper, toy out of reach) rather than attempting alternative solutions.
• Flexibility: Rigid thinking patterns; insists on playing games with the exact same rules every time.
• Inhibition/Impulse Control: Generally cautious physically, though will impulsively throw objects when frustrated.
• Working Memory: Can hold 1–2 step instructions in mind; forgets 3-step directions unless visually supported.

Attention

• Sustained Attention: Sustains attention for 10–15 mins on preferred tabletop activities (e.g., Lego), dropping to < 5 mins for physically demanding or non-preferred academic tasks.
• Selective Attention: Easily distracted by auditory stimuli and movement in the classroom; benefits from seating at the front of the room.
• Divided Attention: Unable to walk and carry an object or hold a conversation simultaneously without increased tripping risk (dual-task interference).

Memory

• Short-Term Memory: Intact for immediate recall of visual information; weaker for auditory-only input.
• Long-Term Memory: Strong recall of routines, favourite facts (dinosaurs), and past family events.
• Episodic Memory: Accurately recalls specific medical appointments and negative past experiences (e.g., previous falls or Botox injections).
• Semantic Memory: Age-appropriate vocabulary and conceptual knowledge.

Language and Communication

• Receptive Language: Understands everyday conversation and simple instructions; struggles with figurative language and complex multi-clause directions.
• Expressive Language: Speaks in 4–6 word sentences. Speech becomes dysarthric and volume drops when physically fatigued.
• Comprehension: Good comprehension of concrete concepts; requires extra processing time (up to 10 seconds) when stressed.

Reasoning and Judgment

• Logical Reasoning: Understands basic cause-and-effect in structured settings.

• Abstract Reasoning: Concrete thinker; unable to grasp abstract concepts or hypothetical scenarios.

• Judgment: Poor physical safety judgment; frequently overestimates his motor capabilities on high playground equipment, creating a high fall risk.

• Impressionability: Easily led by peers; will attempt unsafe physical stunts to gain peer approval.

Social and Community Participation

• Community Activities: Attends RDA weekly and a local inclusive swimming lesson on Sundays.

Social Skills with Familiar People

• Interaction with Family and Friends: Affectionate and chatty with immediate family and support worker. Plays cooperatively alongside 1–2 familiar quiet peers at school.

Social Skills with Unfamiliar People

• Interaction with Strangers: Withdrawn and avoids eye contact; hides behind mother when approached by unfamiliar adults or loud children.

• Community Support: Accesses NDIS-funded support worker for park visits; uneven terrains and lack of accessible playground equipment in local parks limit participation.

Emotional Regulation/ Self-Regulation

• Emotional Responses: Experiences rapid escalation to crying or yelling when physically fatigued, in pain (muscle spasms), or unable to keep up with peers physically.
• Self-Regulation Skills: Emerging; requires co-regulation from an adult once dysregulated.
• Emotional Regulation Strategies: Uses a quiet tent at home, deep pressure (weighted lap pad), and rhythmic movement (rocking) to calm down.

Behaviours of Concern

• Types of Behaviours: Verbal outbursts (screaming), dropping to the floor (refusing to walk), and throwing small items (including AFOs). Occurs 3–4 times per week, lasting 15–20 mins.

• Triggers and Patterns: Primarily triggered by physical exhaustion in the late afternoon, sensory overload in noisy environments, discomfort from AFOs, or unexpected transitions.

• Impact on Daily Functioning: Delays morning school drop-offs; restricts family from attending afternoon community outings; creates safety risks when dropping to the ground in car parks.

• Coping and Management Strategies: Scheduled rest breaks prior to fatigue onset, using the mobility stroller for afternoon transitions, visual schedules, and offering AFO-free time at home. Strategies are moderately effective when applied proactively.

• Response from Others: Parents use calm low-arousal approaches; school peers sometimes stare or avoid him during outbursts, increasing social isolation.

• Revised NDIS GOALS: 1. Maintain and improve lower limb range of motion, strength, and gross motor skills to walk 300 m without falling and navigate school stairs safely. 2. Increase independence in self-care routines, specifically bathroom transfers and dressing, through assistive technology and therapy. 3. Improve emotional regulation and endurance to participate in full school days and weekly community recreational activities.

• Recommendations: 1. Physiotherapy: Continue fortnightly therapy (26 hrs/year) for post-Botox rehabilitation, serial casting/AFO reviews, strength training, and gait re-education. 2. Assistive Technology: Funding for annual bilateral hinged AFO replacements and tuning; trial of a bath transfer bench and grab rails via OT. 3. Support Worker: Increase support worker hours to 6 hrs/week to assist with afternoon care routines during father's FIFO swings and facilitate weekend community access. 4. Multidisciplinary Care: Continue current Speech Pathology, Psychology, and Occupational Therapy inputs for holistic management.