An assessment of Willy’s functional abilities was performed through a family interview. It was reported that Willy’s cognitive and visual-perceptual skills were tested at his school and were found to be age appropriate. Willy demonstrated the ability to perform work that was expected of typically developing students in his grade level. The assessment did, however, reveal that sensorimotor and fine motor skills significantly affected Willy’s ability to participate in ADLs. Willy and his family reported that they particularly wanted to know if Willy could be more independent with feeding, dressing, bathing, and schoolwork.

Willy’s motivation to become more independent with self-care activities was judged to be a significant strength. Clinical observations during task performance showed that Willy required maximum assistance for all bed mobility, transfers, and sitting. Because the severity of the athetoid movements in his right upper extremity did not allow for simple gross assistance with this hand, Willy was noted to use only his left upper extremity for all fine motor tasks. Willy’s left elbow and wrist tended to assume a flexed pattern during all fine motor tasks. He was able to grossly grasp objects between his left fingers and palm, but he was unable to hold a writing instrument or a feeding utensil. Willy was able to isolate his left index finger in order to pint and poke at objects. Occupational therapy sessions focused n the identification of adaptive equipment and techniques that could facilitate independence and ease adaptive and school activities. After several trial sessions, it was concluded that adaptive bathing and dressing equipment would not help Willy in becoming more independent with dressing or bathing. Thus, Willy’s family was instructed to use optimal positioning strategies to ease the burden of Willy’s care for these activities (an elevated reclining tub seat was found to be particularly helpful). A left wrist cock-up splint was constructed and appeared to give Willy better control in maintaining grasp of objects; his self-feeding skills significantly improved when he used the splint. In addition to the splint, a spoon with a built-up handle, an adaptive bowl with a build-up edge to assist with scooping, and a nonslip mat placed under the bowl were incorporated in Willy’s daily living activities. These devices allowed Willy to feed himself thick foods that would stick to his spoon with only minimal assistance. Despite trials with various adaptive writing aids, Willy was not successful with a writing instrument. His keyboard skills were more functional, and with the use of the left wrist cock-up splint and a lap tray that stabilized his left elbow and forearm, his punch rate and accuracy significantly improved. In addition, it was found that when Willy stabilized his right forearm and right hand under the tray, his keyboard control improved even more.

Willy is verbal and conversational, although his speech is severely dysarthric. Willy’s family members find his speech to be fairly intelligible when he speaks slowly in shorter utterances or when the subject of his conversation is known. Unfortunately, for those who do not know Willy, intelligibility is poor. Psychological testing revealed that Willy’s cognitive level is average but that he has a learning disability with poor reading skills. In addition, his nutritional status was poor. When Willy was evaluated, his family also wanted Willy to be more independent with feeding, and they wanted to determine whether drooling could be reduced.

The feeding evaluation revealed that Willy had adequate oral-motor skills to handle all food consistencies. there was no clinical sign of aspiration. His seating, however, was not appropriate, and he was referred to a seating clinic to improve trunk and head position during feeding. However, because of poor manual control, Willy was largely dependent for feeding. Overall growth was minimal but proportional. When nutritional supplements were provided at least twice a day, he began to gain weight. Occupational therapy provided adaptive equipment to foster independence with a spoon.

Willy’s speech was slow and imprecise, and his voice sounded strained-strangled. Pitch and loudness levels were low, and pauses were prolonged and often at inappropriate places in a phrase. Inhalations were sometimes audible.

Speech therapy for Willy was directed toward developing compensatory articulation to allow for independent oral communication with a familiar people. For example, although Willy could not produce most sibilant sounds (e.g., /s/, /z/, /sh/, /ch/, /dg/), he learned to produce a /th/ sound as an acoustic alternative. Because of the high frequency of occurrence of these sounds in English, this helped to improve his overall intelligibility. Willy also learned to use an /n/ (i.e., tongue-tip elevation sound) for the stop consonants /t/ and /d/ and to produce mouth shapes for vowels that were closer to their targets. His phrasing was improved somewhat be reducing the phrase length per breath and by developing more linguistic pause placement.

Despite these improvements, Willy’s speech remained difficult for strangers to understand. In order to develop a supplemental communication system for settings in which his speech was ineffective, Willy was referred for an augmentative communication evaluation.

With regard to his drooling, Willy’s pediatrician recommended a trial of therapy with glycopyrrolate, an anticholinergic medication. On review of the results of this trial, consideration will be given to surgical interventions to control drooling.