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Demographic Details Child's Name: Aadhavan Gupta Age: 6 Year 11 Month 3 Days Gender: Male DOB: 2019-04-25 Mother’s age (years): 42 years Mother’s occupation: Homemaker Father’s age (years): 42 years Father’s occupation: In Life Insurance Company Type of family: Joint Number of family members: 4 Number of siblings: 1 Details of siblings (Age and sex): 4 yr old male Address: DB City Contact: 7389012885 Referred By: Relative Informant: Parents Presenting Concerns Chief concerns: Behavioral issues Interaction history: Eye contact: Suboptimal Quality of Interaction: limited Behavioral history: Repetitive behaviors (RRBs): Looking from corner of eyes, laughing episodes Patterned behavior or activities: Inattention Impulsivity Object obsession Temper tantrums Stubbornness Aggression Emotional history: Irritability Anxiety Sensory Concerns: Auditory: Hypersensitive Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural High-risk factors in pregnancy: PIH Hypothyroidism Others:: 1 MTP (at 14 weeks) Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: LSCS Indication for LSCS (if applicable): Non progression of Labor Gestational Age: FT Birth Weight: 2.8 Kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: No Past history: Hospitalization: No Seizures: No Past/Current therapies: Speech therapy for 3-4 months at 3 years age Past/Current medications: Medicines were given for few months. Investigations done- Hearing assessment: Not done Vision assessment: Not done Family history: Neuropsychiatric condition: No Developmental History: Gross Motor Walking without support: Achieved Age of attainment: 12 months Fine Motor Pincer grasp: Achieved Age of attainment: 12 months Buttoning / Unbuttoning: Achieved Age of attainment: 5 years 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: 4 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Achieved Age of attainment: 4.5 years 2 word Phrases: Achieved Age of attainment: 5 years Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Achieved Age of attainment: 4.5 years 2 word Phrases: Achieved Age of attainment: 5 years Details:: Patterned speech Communication & Language Assessment Non-Verbal Communication Grading:- Following commands (gesture + verbal): 1-step Answering Questions:- Echolalia: Present Patterned speech: Present Social Social smile: Achieved Age of attainment: 2 months Stranger anxiety: Achieved Age of attainment: 8 months Waving bye bye: Achieved Age of attainment: 12 months Comes when called: Achieved Age of attainment: Asking for food and toilet: Achieved Age of attainment: Response to Name Call Sitting tolerance- (in minutes) For interaction: 2 minutes For tasks: Better for activities ADL Skills (Age-appropriate)- Eating: 5. Independent Bathing: 4. Needs minimal assistance Toilet training: 5. Independent Dressing: 5. Independent Undressing: 5. Independent Details:: Toilet trained at 4 years. Difficult in shoe lacing Academic History: Is child enrolled in school: Yes Type of school: Regular Name of School: Pragati- Its Different Grade: 2 Hours spent in school: 5 hours Location: New Collectorate Diet History: Food allergies: No Junk food intake: Occasional Sleep History Total sleep duration (night): 8 hours Afternoon nap: No Daily Screen Time Duration: <30 minutes Type of screen: TV Examination a. Vitals: b. Anthropometry: Height: 122 cm Head circumference: 53.5 cm c. General Examination Dysmorphology: Absent Neurocutaneous markers: Absent d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Oromotor Examination Drooling: No Chewing: Proper Swallowing: Proper Blowing: Proper Sucking: Proper CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Impression: ASD Advice Intervention plan: IDP 2/week +PMT 1/week Evaluation: ISAA, DSM5 ASD (later) Follow up plan: Once in a month General recommendation- Zero Screen Time Physical interactive play No Junk food No focus on academics at present

Demographic Details

Child's Name: Aadhavan Gupta
Age: 6 Year 11 Month 3 Days
Gender: Male
DOB: 2019-04-25
Mother’s age (years): 42 years
Mother’s occupation: Homemaker
Father’s age (years): 42 years
Father’s occupation: In Life Insurance Company
Type of family: Joint
Number of family members: 4
Number of siblings: 1
Details of siblings (Age and sex): 4 yr old male
Address: DB City
Contact: 7389012885
Referred By: Relative
Informant: Parents

Presenting Concerns

Chief concerns: Behavioral issues

Interaction history:

Eye contact: Suboptimal
Quality of Interaction: limited

Behavioral history:

Repetitive behaviors (RRBs): Looking from corner of eyes, laughing episodes Patterned behavior or activities: Inattention Impulsivity Object obsession Temper tantrums Stubbornness Aggression Emotional history:
Irritability Anxiety
Sensory Concerns:

Auditory: Hypersensitive

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural
High-risk factors in pregnancy:
1. PIH
2. Hypothyroidism
Others:: 1 MTP (at 14 weeks)

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: LSCS
Indication for LSCS (if applicable): Non progression of Labor
Gestational Age: FT
Birth Weight: 2.8 Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: No

Past history:

Hospitalization: No Seizures: No

Past/Current therapies: Speech therapy for 3-4 months at 3 years age Past/Current medications: Medicines were given for few months. Investigations done-

Hearing assessment: Not done Vision assessment: Not done

Family history:

Neuropsychiatric condition: No

Developmental History:

Gross Motor

Walking without support: Achieved

Age of attainment: 12 months

Fine Motor

Pincer grasp: Achieved

Age of attainment: 12 months

Buttoning / Unbuttoning: Achieved

Age of attainment: 5 years

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: 4 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Achieved

Age of attainment: 4.5 years

2 word Phrases: Achieved

Age of attainment: 5 years

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Achieved

Age of attainment: 4.5 years

2 word Phrases: Achieved

Age of attainment: 5 years

Details:: Patterned speech

Communication & Language Assessment

Non-Verbal Communication Grading:-

Following commands (gesture + verbal): 1-step

Answering Questions:-

Echolalia: Present Patterned speech: Present

Social

Social smile: Achieved

Age of attainment: 2 months
Stranger anxiety: Achieved

Age of attainment: 8 months
Waving bye bye: Achieved

Age of attainment: 12 months
Comes when called: Achieved

Age of attainment:
Asking for food and toilet: Achieved

Age of attainment:

Response to Name Call

Sitting tolerance- (in minutes)

For interaction: 2 minutes
For tasks: Better for activities

ADL Skills (Age-appropriate)-

Eating: 5. Independent
Bathing: 4. Needs minimal assistance
Toilet training: 5. Independent
Dressing: 5. Independent
Undressing: 5. Independent

Details:: Toilet trained at 4 years. Difficult in shoe lacing

Academic History:

Is child enrolled in school: Yes
Type of school: Regular
Name of School: Pragati- Its Different
Grade: 2
Hours spent in school: 5 hours
Location: New Collectorate

Diet History:

Food allergies: No
Junk food intake: Occasional

Sleep History

Total sleep duration (night): 8 hours
Afternoon nap: No

Daily Screen Time

Duration: <30 minutes
Type of screen: TV

Examination

a. Vitals:

b. Anthropometry:

Height: 122 cm Head circumference: 53.5 cm

c. General Examination

Dysmorphology: Absent Neurocutaneous markers: Absent

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Oromotor Examination

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

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

Impression: ASD

Advice

Intervention plan: IDP 2/week +PMT 1/week
Evaluation: ISAA, DSM5 ASD (later)
Follow up plan: Once in a month
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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