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Demographic Details Child's Name: Zoiv khan Age: 5 Year 10 Month 26 Days Gender: Male DOB: 2020-03-18 Mother’s age (years): 28 years Mother’s occupation: Homemaker Father’s age (years): 32 years Father’s occupation: Pvt job Type of family: Joint Number of family members: 12 Number of siblings: 1 Details of siblings (Age and sex): 1- 3 year old male Address: Gol pahadiya Contact: 8718869760 Referred By: Doctor Informant: Parents Presenting Concerns Chief concerns: Behavioral concerns- inattention, impulsivity Duration of symptoms: Since infancy- sleep disturbances and behavioral abnormalities Interaction history: Eye contact: Suboptimal Interaction: Better with known people, not with others Quality of Interaction: limited Behavioral history: Repetitive behaviors (RRBs): Hyperactivity Inattention Impulsivity Temper tantrums Stubbornness Aggression Emotional history: Irritability Birth & Perinatal History: Antenatal History Consanguinity: Yes If yes Degree: 3 Maternal age at conception (years):: 22 Type of conception: Natural High-risk factors in pregnancy: PIH Others:: H/o 1 spontaneous abortion (at 2.5 month) Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: NVD Gestational Age: 37 weeks Birth Weight: 2.4 kg Cry at birth: Cried after stimulation NICU stay: Yes If yes- Duration & Indication: H/o meconium aspiration at birth. Kept in NICU under observation for 1 hour. Past history: Hospitalization: No Seizures: No Others: H/o jaundice at 3 years age Past/Current therapies: Nil Past/Current medications: Syp sizodon 5drops BD for 6 months. Stopped by themselves in view of no improvement. Investigations done- Hearing assessment: Done Details: BERA- normal Vision assessment: Not done Family history: Neuropsychiatric condition: No Others: ? Psychiatric illness in Paternal Grandmother. On medications. Developmental History: Gross Motor Neck holding: Achieved Age of attainment: 3-4 months Roll over: Achieved Age of attainment: 5 months Sitting without support: Achieved Age of attainment: 6 months Standing without support: Achieved Age of attainment: 10 months Walking without support: Achieved Age of attainment: 14 months Fine Motor Bidextrous grasp: Achieved Age of attainment: 4 months Unidextrous grasp: Achieved Age of attainment: 6 months Pincer grasp: Achieved Age of attainment: 12 months Buttoning / Unbuttoning: Not achieved Language Receptive:- Joint attention: Achieved Age of attainment: 9 months Pointing: Achieved Age of attainment: 12 months Following commands: 1-step Expressive:- Cooing: Achieved Age of attainment: 3 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Not achieved Expressive:- Cooing: Achieved Age of attainment: 3 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Not achieved Communication & Language Assessment Non-Verbal Communication Grading:- Need-based communication: Emerging Answering Questions:- Echolalia: Present Patterned speech: Present Social Social smile: Achieved Age of attainment: 2 months Stranger anxiety: Achieved Age of attainment: 7 months Comes when called: Achieved Age of attainment: 12 months Response to Name Call Sitting tolerance- (in minutes) For interaction: Doesnt sit for 1-2 minutes For tasks: Able to sit for tasks of his choice ADL Skills (Age-appropriate)- Eating: 2. Started attempting Bathing: 2. Started attempting Toilet training: 2. Started attempting Dressing: 2. Started attempting Undressing: 2. Started attempting Academic History: Is child enrolled in school: Yes Type of school: Regular Name of School: Sadhna Vidya Mandir Grade: Nursery Hours spent in school: 4 hours Location: Gol Pahadiya Diet History: Junk food intake: Daily (Chips) Sleep History Total sleep duration (night): 9 hours Afternoon nap: No Sleep disturbances: Yes Daily Screen Time Duration: > 5 hours Type of screen: Mobile Examination a. Vitals: b. Anthropometry: c. General Examination d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Oromotor Examination Drooling: No Chewing: Proper Swallowing: Proper Blowing: Proper CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: Poor self regulation Advice Intervention plan: IDP 1/week + PMT 1/week Investigations: DQ, ISAA, DSM5 ADHD (Later) General recommendation- Zero Screen Time Physical interactive play No Junk food No focus on academics at present

Demographic Details

Child's Name: Zoiv khan
Age: 5 Year 10 Month 26 Days
Gender: Male
DOB: 2020-03-18
Mother’s age (years): 28 years
Mother’s occupation: Homemaker
Father’s age (years): 32 years
Father’s occupation: Pvt job
Type of family: Joint
Number of family members: 12
Number of siblings: 1
Details of siblings (Age and sex): 1- 3 year old male
Address: Gol pahadiya
Contact: 8718869760
Referred By: Doctor
Informant: Parents

Presenting Concerns

Chief concerns: Behavioral concerns- inattention, impulsivity
Duration of symptoms: Since infancy- sleep disturbances and behavioral abnormalities

Interaction history:

Eye contact: Suboptimal
Interaction: Better with known people, not with others
Quality of Interaction: limited

Behavioral history:

Repetitive behaviors (RRBs): Hyperactivity Inattention Impulsivity Temper tantrums Stubbornness Aggression Emotional history:
Irritability

Birth & Perinatal History: Antenatal History

Consanguinity: Yes
If yes Degree: 3
Maternal age at conception (years):: 22
Type of conception: Natural
High-risk factors in pregnancy:
1. PIH
Others:: H/o 1 spontaneous abortion (at 2.5 month)

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: NVD
Gestational Age: 37 weeks
Birth Weight: 2.4 kg
Cry at birth: Cried after stimulation
NICU stay: Yes
If yes- Duration & Indication: H/o meconium aspiration at birth. Kept in NICU under observation for 1 hour.

Past history:

Hospitalization: No Seizures: No Others: H/o jaundice at 3 years age

Past/Current therapies: Nil Past/Current medications: Syp sizodon 5drops BD for 6 months. Stopped by themselves in view of no improvement. Investigations done-

Hearing assessment: Done Details: BERA- normal Vision assessment: Not done

Family history:

Neuropsychiatric condition: No Others: ? Psychiatric illness in Paternal Grandmother. On medications.

Developmental History:

Gross Motor

Neck holding: Achieved

Age of attainment: 3-4 months
Roll over: Achieved

Age of attainment: 5 months
Sitting without support: Achieved

Age of attainment: 6 months
Standing without support: Achieved

Age of attainment: 10 months
Walking without support: Achieved

Age of attainment: 14 months

Fine Motor

Bidextrous grasp: Achieved

Age of attainment: 4 months

Unidextrous grasp: Achieved

Age of attainment: 6 months

Pincer grasp: Achieved

Age of attainment: 12 months

Buttoning / Unbuttoning: Not achieved

Language

Receptive:-

Joint attention: Achieved

Age of attainment: 9 months
Pointing: Achieved

Age of attainment: 12 months
Following commands: 1-step

Expressive:-

Cooing: Achieved

Age of attainment: 3 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Not achieved

Expressive:-

Cooing: Achieved

Age of attainment: 3 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Not achieved

Communication & Language Assessment

Non-Verbal Communication Grading:-

Need-based communication: Emerging

Answering Questions:-

Echolalia: Present Patterned speech: Present

Social

Social smile: Achieved

Age of attainment: 2 months
Stranger anxiety: Achieved

Age of attainment: 7 months
Comes when called: Achieved

Age of attainment: 12 months

Response to Name Call

Sitting tolerance- (in minutes)

For interaction: Doesnt sit for 1-2 minutes
For tasks: Able to sit for tasks of his choice

ADL Skills (Age-appropriate)-

Eating: 2. Started attempting
Bathing: 2. Started attempting
Toilet training: 2. Started attempting
Dressing: 2. Started attempting
Undressing: 2. Started attempting

Academic History:

Is child enrolled in school: Yes
Type of school: Regular
Name of School: Sadhna Vidya Mandir
Grade: Nursery
Hours spent in school: 4 hours
Location: Gol Pahadiya

Diet History:

Junk food intake: Daily (Chips)

Sleep History

Total sleep duration (night): 9 hours
Afternoon nap: No
Sleep disturbances: Yes

Daily Screen Time

Duration: > 5 hours
Type of screen: Mobile

Examination

a. Vitals:

b. Anthropometry:

c. General Examination

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Oromotor Examination

Drooling: No
Chewing: Proper
Swallowing: Proper
Blowing: Proper

CVS examination: NAD
Respiratory System examination: NAD
Per abdomen examination: NAD

Impression: Poor self regulation

Advice

Intervention plan: IDP 1/week + PMT 1/week
Investigations: DQ, ISAA, DSM5 ADHD (Later)
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food
4. No focus on academics at present

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