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Demographic Details Child's Name: Bani Kaur Age: 2 Year 9 Month 29 Days Gender: Female DOB: 2023-04-26 Mother’s age (years): 33years Mother’s occupation: Homemaker Father’s age (years): 33 years Father’s occupation: Business (barnala) Type of family: Joint Number of family members: 3 Number of siblings: 0 Address: Currently In Bohdapur Contact: 6283873365 Referred By: Doctor Informant: Mother, maternal grandmother Presenting Concerns Chief concerns: Hyperactivity, inattention Interaction history: Eye contact: Suboptimal Interaction: Initiates interaction inconsistently Quality of Interaction: limited Behavioral history: Hyperactivity Inattention Impulsivity Temper tantrums Stubbornness Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural Natal and Postnatal History: Place of Birth: Institutional Mode of Delivery: LSCS Indication for LSCS (if applicable): H/o active asthma in mother Gestational Age: FT Birth Weight: 2.5Kg Cry at birth: Cried immediately after birth Resuscitation required: No NICU stay: No Past history: Hospitalization: No Seizures: No Past/Current medications: sizodon started since 3-4 days Investigations done- Hearing assessment: Done Family history: Neuropsychiatric condition: Yes Developmental History: Gross Motor Neck holding: Achieved Age of attainment: 4 months Roll over: Achieved Age of attainment: 7 months Sitting without support: Achieved Age of attainment: 9 months Standing without support: Achieved Age of attainment: 18 months Walking without support: Achieved Age of attainment: 24 months Fine Motor Bidextrous grasp: Achieved Age of attainment: 12 months Unidextrous grasp: Achieved Age of attainment: 14 months Pincer grasp: Achieved Age of attainment: 18 months Drinking from cup: Achieved Age of attainment: 24 months Language Receptive:- Pointing: Achieved Age of attainment: 24 months Understanding gestures: Achieved Age of attainment: 30 months Following commands: Not following Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Communication & Language Assessment Non-Verbal Communication Grading:- Answering Questions:- Social Social smile: Achieved Age of attainment: 12 months Waving bye bye: Achieved Age of attainment: 24 months Comes when called: Not achieved Response to Name Call Sitting tolerance- (in minutes) For interaction: Less than one minute For tasks: Less than one minute, object oriented ADL Skills (Age-appropriate)- Eating: 1. Dependent Bathing: 1. Dependent Toilet training: 1. Dependent Dressing: 1. Dependent Undressing: 1. Dependent Academic History: Additional information: Tells for hunger and toilet by gestures and pointing Diet History: Food preferences: Picky eater, bottlefeeding Food allergies: No Sleep History Total sleep duration (night): 7-8 hours Afternoon nap: Yes Sleep disturbances: Yes Daily Screen Time Duration: > 2 hours Examination a. Vitals: b. Anthropometry: c. General Examination Neurocutaneous markers: Ab d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Tone: Hypotonia Deep tandon reflexes: DTR- KJ1+/1+, AJ1+,1+ If present details: Sits in W position Oromotor Examination Drooling: No Chewing: Proper Swallowing: Proper Blowing: Proper Others: Sucking- poor CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Advice Intervention plan: IDP (1/week)+ PMT (1/week) General recommendation- Zero Screen Time Physical interactive play No Junk food No focus on academics at present

Demographic Details

Child's Name: Bani Kaur
Age: 2 Year 9 Month 29 Days
Gender: Female
DOB: 2023-04-26
Mother’s age (years): 33years
Mother’s occupation: Homemaker
Father’s age (years): 33 years
Father’s occupation: Business (barnala)
Type of family: Joint
Number of family members: 3
Number of siblings: 0
Address: Currently In Bohdapur
Contact: 6283873365
Referred By: Doctor
Informant: Mother, maternal grandmother

Presenting Concerns

Chief concerns: Hyperactivity, inattention

Interaction history:

Eye contact: Suboptimal
Interaction: Initiates interaction inconsistently
Quality of Interaction: limited

Behavioral history:

Hyperactivity Inattention Impulsivity Temper tantrums Stubbornness

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural

Natal and Postnatal History:

Place of Birth: Institutional
Mode of Delivery: LSCS
Indication for LSCS (if applicable): H/o active asthma in mother
Gestational Age: FT
Birth Weight: 2.5Kg
Cry at birth: Cried immediately after birth
Resuscitation required: No
NICU stay: No

Past history:

Hospitalization: No Seizures: No

Past/Current medications: sizodon started since 3-4 days Investigations done-

Hearing assessment: Done

Family history:

Neuropsychiatric condition: Yes

Developmental History:

Gross Motor

Neck holding: Achieved

Age of attainment: 4 months
Roll over: Achieved

Age of attainment: 7 months
Sitting without support: Achieved

Age of attainment: 9 months
Standing without support: Achieved

Age of attainment: 18 months
Walking without support: Achieved

Age of attainment: 24 months

Fine Motor

Bidextrous grasp: Achieved

Age of attainment: 12 months

Unidextrous grasp: Achieved

Age of attainment: 14 months

Pincer grasp: Achieved

Age of attainment: 18 months

Drinking from cup: Achieved

Age of attainment: 24 months

Language

Receptive:-

Pointing: Achieved

Age of attainment: 24 months
Understanding gestures: Achieved

Age of attainment: 30 months
Following commands: Not following

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling:

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling:

Communication & Language Assessment

Non-Verbal Communication Grading:-

Answering Questions:-

Social

Social smile: Achieved

Age of attainment: 12 months
Waving bye bye: Achieved

Age of attainment: 24 months
Comes when called: Not achieved

Response to Name Call

Sitting tolerance- (in minutes)

For interaction: Less than one minute
For tasks: Less than one minute, object oriented

ADL Skills (Age-appropriate)-

Eating: 1. Dependent
Bathing: 1. Dependent
Toilet training: 1. Dependent
Dressing: 1. Dependent
Undressing: 1. Dependent

Academic History:

Additional information: Tells for hunger and toilet by gestures and pointing

Diet History:

Food preferences: Picky eater, bottlefeeding
Food allergies: No

Sleep History

Total sleep duration (night): 7-8 hours
Afternoon nap: Yes
Sleep disturbances: Yes

Daily Screen Time

Duration: > 2 hours

Examination

a. Vitals:

b. Anthropometry:

c. General Examination

Neurocutaneous markers: Ab

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Tone: Hypotonia
Deep tandon reflexes: DTR- KJ1+/1+, AJ1+,1+

If present details: Sits in W position

Oromotor Examination

Drooling: No
Chewing: Proper
Swallowing: Proper
Blowing: Proper
Others: Sucking- poor

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

Advice

Intervention plan: IDP (1/week)+ PMT (1/week)
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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