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Demographic Details Child's Name: sonia Age: 4 Year 5 Month 4 Days Gender: Female DOB: 2021-10-10 Mother’s age (years): 26 years Mother’s occupation: Homemaker Father’s age (years): 31 years Father’s occupation: Farmer Type of family: Joint Number of family members: 7 Number of siblings: 1 Details of siblings (Age and sex): 1-2.5 years Contact: 8959683616 Referred By: Doctor Presenting Concerns Chief concerns: Poor understanding, abnormal movements Duration of symptoms: Symptoms noticed since 2.5 years. During infancy excessive crying Interaction history: Eye contact: Suboptimal Interaction: Poor Quality of Interaction: limited Behavioral history: Repetitive behaviors (RRBs): Hyperactivity Inattention Impulsivity Temper tantrums Stubbornness Aggression Mouthing of objects Separation anxiety Sensory Concerns: Vestibular: Seeks movement Birth & Perinatal History: Antenatal History Consanguinity: No Type of conception: Natural Natal and Postnatal History: Place of Birth: Institutional Gestational Age: FT Birth Weight: Not known Cry at birth: Cried after stimulation Resuscitation required: No NICU stay: No Past history: Hospitalization: Yes Seizures: Yes Others: At 2.5 years abnormal body movements , varied presentation, not associated with fever, occurs in sleep also, no LOC, 2-4 times in a day. Past/Current medications: EEG (May 2024)- Abnormal. AEDs were started. Repeat EEG (2025)- abnormal. On syp Levilex Investigations done- Hearing assessment: Not done Vision assessment: Not done Family history: Neuropsychiatric condition: No Developmental History: Gross Motor Neck holding: Achieved Age of attainment: 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: 12 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 Language Receptive:- Joint attention: Achieved Age of attainment: 9 months Pointing: Achieved Age of attainment: 12 months Understanding gestures: Achieved Age of attainment: Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Achieved Age of attainment: 3 years Expressive:- Cooing: Achieved Age of attainment: 4 months Babbling: Achieved Age of attainment: 6 months Meaningful words: Achieved Age of attainment: 3 years Details:: Kinship words, uses 2-3 words phrases with meaning Communication & Language Assessment Non-Verbal Communication Grading:- Understanding gestures: Emerging Answering Questions:- Echolalia: Present Social Social smile: Achieved Age of attainment: 2 months Stranger anxiety: Achieved Age of attainment: 7 months Waving bye bye: Not achieved Response to Name Call Details: 4/10 Sitting tolerance- (in minutes) For interaction: Doesnt sit For tasks: Better for objects ADL Skills (Age-appropriate)- Eating: 4. Needs minimal assistance Bathing: 3. Needs significant assistance Toilet training: 3. Needs significant assistance Dressing: 2. Started attempting Undressing: 2. Started attempting Details:: Goes to toilet herself Type of Play : 2. Isolated Academic History: Is child enrolled in school: Yes Type of school: Regular Name of School: - Location: Dabra Additional information: Goes irregularly, comes back- says herself that school is closed Diet History: Food allergies: No Sleep History Afternoon nap: Yes Sleep disturbances: Daily Screen Time Duration: > 5 hours Examination a. Vitals: b. Anthropometry: Height: 98 cm Head circumference: 47 cm c. General Examination Dysmorphology: Ab Neurocutaneous markers: Ab d. CNS: Higher Mental Functions Sensory Examination Cranial Nerves (1–12) Neuromuscular Concerns Oromotor Examination CVS examination: NAD Respiratory System examination: NAD Per abdomen examination: NAD Advice Intervention plan: IDP 2/week, PMT 1/week Investigations: DQ evaluation Medications: Continue AEDs as advised by pediatrician. General recommendation- Zero Screen Time Physical interactive play No Junk food

Demographic Details

Child's Name: sonia
Age: 4 Year 5 Month 4 Days
Gender: Female
DOB: 2021-10-10
Mother’s age (years): 26 years
Mother’s occupation: Homemaker
Father’s age (years): 31 years
Father’s occupation: Farmer
Type of family: Joint
Number of family members: 7
Number of siblings: 1
Details of siblings (Age and sex): 1-2.5 years
Contact: 8959683616
Referred By: Doctor

Presenting Concerns

Chief concerns: Poor understanding, abnormal movements
Duration of symptoms: Symptoms noticed since 2.5 years. During infancy excessive crying

Interaction history:

Eye contact: Suboptimal
Interaction: Poor
Quality of Interaction: limited

Behavioral history:

Repetitive behaviors (RRBs): Hyperactivity Inattention Impulsivity Temper tantrums Stubbornness Aggression Mouthing of objects Separation anxiety
Sensory Concerns:

Vestibular: Seeks movement

Birth & Perinatal History: Antenatal History

Consanguinity: No
Type of conception: Natural

Natal and Postnatal History:

Place of Birth: Institutional
Gestational Age: FT
Birth Weight: Not known
Cry at birth: Cried after stimulation
Resuscitation required: No
NICU stay: No

Past history:

Hospitalization: Yes Seizures: Yes Others: At 2.5 years abnormal body movements , varied presentation, not associated with fever, occurs in sleep also, no LOC, 2-4 times in a day.

Past/Current medications: EEG (May 2024)- Abnormal. AEDs were started. Repeat EEG (2025)- abnormal. On syp Levilex Investigations done-

Hearing assessment: Not done Vision assessment: Not done

Family history:

Neuropsychiatric condition: No

Developmental History:

Gross Motor

Neck holding: Achieved

Age of attainment: 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: 12 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

Language

Receptive:-

Joint attention: Achieved

Age of attainment: 9 months
Pointing: Achieved

Age of attainment: 12 months
Understanding gestures: Achieved

Age of attainment:

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Achieved

Age of attainment: 3 years

Expressive:-

Cooing: Achieved

Age of attainment: 4 months

Babbling: Achieved

Age of attainment: 6 months

Meaningful words: Achieved

Age of attainment: 3 years

Details:: Kinship words, uses 2-3 words phrases with meaning

Communication & Language Assessment

Non-Verbal Communication Grading:-

Understanding gestures: Emerging

Answering Questions:-

Echolalia: Present

Social

Social smile: Achieved

Age of attainment: 2 months
Stranger anxiety: Achieved

Age of attainment: 7 months
Waving bye bye: Not achieved

Response to Name Call

Details: 4/10

Sitting tolerance- (in minutes)

For interaction: Doesnt sit
For tasks: Better for objects

ADL Skills (Age-appropriate)-

Eating: 4. Needs minimal assistance
Bathing: 3. Needs significant assistance
Toilet training: 3. Needs significant assistance
Dressing: 2. Started attempting
Undressing: 2. Started attempting

Details:: Goes to toilet herself

Type of Play : 2. Isolated Academic History:

Is child enrolled in school: Yes
Type of school: Regular
Name of School: -
Location: Dabra
Additional information: Goes irregularly, comes back- says herself that school is closed

Diet History:

Food allergies: No

Sleep History

Afternoon nap: Yes
Sleep disturbances:

Daily Screen Time

Duration: > 5 hours

Examination

a. Vitals:

b. Anthropometry:

Height: 98 cm Head circumference: 47 cm

c. General Examination

Dysmorphology: Ab Neurocutaneous markers: Ab

d. CNS: Higher Mental Functions

Sensory Examination

Cranial Nerves (1–12)

Neuromuscular Concerns

Oromotor Examination

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

Advice

Intervention plan: IDP 2/week, PMT 1/week
Investigations: DQ evaluation
Medications: Continue AEDs as advised by pediatrician.
General recommendation-
1. Zero Screen Time
2. Physical interactive play
3. No Junk food

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