Child Information Example 1

Here are two actual child information example sheets that will help with telling your story and child introduction for your special needs child. The first is the one I made for our daughter Cosette and the next is the son of family friends (with all identifying information removed) to give you a good idea of a couple different ways of putting together a manual on your child. This is a great way to introduce your child with necessary child information and really help with telling your story!

Cosette Nichole

Intelligent

Loves books & reads well

Trusting

Respectful

Wants to fit in socially

Hard worker

Enjoys being around others

Likes to ride horses

Likes art

Likes to cook

Loves dogs

Synopsis for Cosette

(use this child information example sheet as a guide to help with your child introduction and telling your story. Use only the parts that apply or that you think will help whomever you are giving this child information sheet to understand and better be able to work with your child)

DIAGNOSIS: (always start with the positive about your child before you include the challenges in the child information sheet).

Cosette has been diagnosed with Pervasive Developmental Disorder Not Otherwise Specified (PDD NOS), Bipolar Disorder Not Otherwise Specified, and Sensory Integration Dysfunction.

Emotional Health and Development: (Important child information)

Cosette has been diagnosed by the WMU Center for Autism, her psychiatrist at Kalamazoo Community Mental Health and Substance Abuse Services, and her Occupational Therapist at WMU. Cosette demonstrates symptoms consistent with an autism spectrum disorder, which has resulted in her diagnosis of PDD NOS. Cosette has carried the diagnosis of Pervasive Developmental Disorder since the age of two due to social/emotional and academic delays. Cosette has received special education services through the local school district for the majority of her academic career because her symptoms interfere with her learning.

Symptoms of autism spectrum disorder and PDD NOS

These symptoms in Cosette are manifested by a difficulty in recognizing and implementing appropriate social interaction skills. This means that Cosette has difficulty reading social cues and engaging in a conversation.

Cosette has a tendency to perseverate on issues; i.e., she will show an intense interest in something and be unable to discuss or engage in anything other than the issue she is focused on. Cosette has intolerance for a change in her routine and has difficulty adapting to a new and unfamiliar environment.

Cosette’s intellectual capacity is within normal limits; however, she can verbalize more than she can actually process leading the casual observer to assume she understands more than she does in any given situation. This means that Cosette may have difficulty following multi-step directions or directions that aren’t very detailed.

Cosette gets distracted easily and therefore has a tendency to wander off if unsupervised; this can pose a threat to her safety.

Symptoms of Bipolar Disorder NOS

These symptoms in Cosette include a quick temper and at times an inability to appropriately handle her frustrations without getting extremely angry. She has experienced auditory hallucinations in the past; however, current medications seem to have addressed this.

Symptoms of Sensory Integration Dysfunction

These symptoms in Cosette manifest as difficulty sleeping, as well as distractibility. Cosette seeks out sensory experiences due to an under-reactive arousal system, and she has difficulty with spatial awareness; i.e., she is unaware of her surroundings and often bumps into things. She also has trouble with coordination.

Current Status: (current child information status - as opposed to historical reference)

Educational:

Cosette is currently home-schooled due to the anxiety she has when in a public school placement. Cosette performs academically at various grade levels due to difficulty with the multi-step processing that different subjects require. Cosette participates in frequent community outings/activities as part of her home-school courses.

Safety: (child information example of things to keep your child safe)

Cosette has recently completed a community safety course that has improved her ability to follow directions or take a short walk in the neighborhood without getting lost or sidetracked. The biggest concern is Cosette’s lack of spatial awareness and her tendency to perseverate on only one thing. This can cause her to unintentionally ignore potential safety threats in her environment.

Social/Recreational: (child information example of things your child enjoys or is good at doing)

Cosette has participated in golf and nature programs this summer. Cosette would like to continue with golf this fall. Currently Cosette attends a church youth group, uses the local library, and camps with her family. She is also a member of Calling All Youth (youth organizations through Kalamazoo Wraps), the YMCA, and has attended The Zoo School at Binder Park School.

Coping/De-escalation Techniques: (the "what to do" part of telling your story)

Cosette is calmed by music, reading, or sometimes taking space away from people and/or noise if the situation she is in is frustrating to her. She uses a weighted blanket at night as well.

Some signs that Cosette may exhibit if she is under stress are: withdrawal from the situation, she may fidget and seem anxious, and/or she may appear tired and won’t feel well. Sometimes eating crunchy foods or chewing gum can calm her and/or refocus her.

PHYSICAL HEALTH:

Cosette is Gluten-intolerant, has allergies to grain and soy, milk, and lactose, and has Asthma, Eczema, and Reflux.

Current Status: (included as needed)

Safety: (attach)

Medical: (attach)

Asthma Plan: (attach)

Medications: (attach)

Allergy Plan: (attach)

IMPORTANT PEOPLE IN COSETTE’S LIFE:

Mom and Dad

Sisters

Grandparents

Church Youth Group Leaders

Peers in her Social Skills OT Group

Elizabeth (friend of Cosette)

Nichole (Big Sister)

Contact Information: (include whoever is needed for the specific purpose with this child information sheet as your story)

Back to Start Here page

Child Information Example 2

Resource Synopsis for Jimbob

A Guide for Important People in Jimbob’s Life

A picture of the child would go here…

Use a current picture, such as a studio portrait or school picture,

or

use a picture of the child doing something they enjoy or shows

something unique and positive about them.

(Note: always starts with strengths and interests as indicated in both of these child information example sheets, and use this as the standard in telling your story)Strengths and Interests

• Friendly – not shy at all

• Wants to please

• Tries to make friends

• Excellent vocabulary

• Loves how things work. Mechanically minded

• Jacob has a good imagination

• Interests:

Machinery, Construction, Farm Equipment, Aircraft, Aircraft Carriers, Star Wars, Transformers. Enjoys television related to the above: How it's Made, Myth busters, Modern Marvels, Extreme Movers, Dirty Jobs

(Child information relating to their diagnosis - describe the challenges)

Asperger and Sensory Integration Dysfunction Manifestation

• Obsessed with machinery of all types, especially lately Aircraft. Will try and talk about these things above other subjects

• Has a hard time with transitions – Audio/Visual cues needed prior to change

• A lot of change at one time is difficult. For example different substitute teachers every day could cause stress

• Stress indicators - hyperactivity, excessive silliness, grouchiness, whining, drooling, fixations. These are “rumblings” that could lead to out of control behavior or a “meltdown” left unchecked

• Occasionally he will get fixated on something, usually something he wants or wants to do. This is more frequent when he under more stress

• Body space, Fine Motor, Gross Motor Issues

Brief History

This section is optional, depending on how much background information is required. Include for doctors, therapists, school personnel, or people who need a deeper understanding of where your child is coming from.

Include a chronological history of symptoms observed, diagnosis and medication, specialized schools, therapies, diets, and interventions that have been implemented for your child.

Child Information Example:

• Fall 2004 to Summer 2005. Age 3-4 Years Old – Early Intervention diagnosed Jimbob with Sensory Integration Disorder. He received speech, OT and teacher services for 1 year.

• Fall 2005 Age 4 – Jimbob enrolled in. Speech and Language Delay was the qualifying diagnosis. He tested out in October 2004.

• Fall 2005 to Spring 2006. Age 4– Enrolled in Preschool at School Name. Although informal consultative resource was made available, it was not used. Jacob was in a regular class with no support. This was a miserable failure.

• Summer 2006 – We began the process of having Jimbob medically evaluated at the Western Michigan University Center for Autism.

Go as far back as needed, and include enough child information detail to provide an understanding of what you and your child have been through, and a historical record of what has been tried and whether or not it worked. You could also save this page out as a separate reference for filling out the history paper work where ever you go.

Current Status (This is the child information that can be used to help your child now)

This section can be as brief or as detailed as needed to help those who are working with and caring for your child to be successful.

Social/Emotional

• Immature for age

• Emotional responses that are not in proportion for the situation

• Sharing is a work in progress

• Frustration

Gross Motor

• Clumsy

• Weak upper body strength

Fine Motor

• Tends to push too hard with crayon or pencil

• Has trouble with printing letters, especially curved ones. Needs allot of positive reinforcement and encouragement. He gets frustrated easily with this task

• We have been working on hand writing at home using the “Handwriting Without Tears” workbooks

Proprioception

• Has trouble with the concept of body space – Has become remarkably better. Is a problem mostly when he is in line or sitting in a group

• Stands/sits too close to people and objects

• He especially has a hard time standing in line. Does best at either the front or back of the line so he is not “sandwiched” between others. We have been working on this. We start him in the front of the line and then gradually moving him back a place or two in the line. We teach him to be approximately an arms length away

• For circle time on the floor, we have found that Jimbob does well if he is given a particular place to sit. (Your place to sit will be on the letter B.)

Transitions

• Jimbob has a hard time with changes in routine and transitions.

• He responds well when he is given notice. (In 5 minutes we will be putting the Lego's away and it will be time to start circle time) or advance notice of changes in routine.

• Verbal as well as visual cues are helpful.

Sensory

• Poor eye contact or avoids eye contact.

• We tell Jimbob to look at our face when we are talking.

• He will drool on a bad sensory day or he is in a state of “agitation”.

Self Care Activities

• He can zip up his coat if you start it for him.

• He can not do buttons at this time. This is something we are working on.

• I replaced any buttons in his pants with snaps.

• He is potty trained but is sometimes not careful when pulling up and down his underwear and pants.

Energy Rating Level

• We are trying to help Jimbob recognize how his engine is running by using the rating system. He understands what the numbers mean and that he needs to try to stay in the 0-1 level. When he gets too hyper or excited it is difficult for him to calm down.

• Our goal is for him to be able to recognize when his engine is running at a 2 and be able to self regulate.

• 0=Low Energy Level: like story time or other sit down low energy

• Right Energy Level: Normal energy level for most activities and conversation.

• 2=High Energy Level (Too Hyper) – OK for outside physical games, but not OK for everyday activities and conversation

Being OK

• We use this term with him and he understands what it means.

• “Being OK” means letting go of a problem and being able to do something different or new. It means minimizing of a problem, issue, situation or concern. When we do this, we just move on and accept whatever it is or let go and be done with it.

• We use this phrase to help Jimbob move on when he gets fixated and we are trying to redirect him. We use it also as a preventative measure.

Timeouts/Meltdowns (this is a child information example that helps with the "what to do" part of it.)

• Jimbob will usually go to the “Red Choice Chair” without problems. Make sure he understands what he did wrong. Explain in as few words as possible. Some times he doesn't make the connection.

• We don't talk to him during the time out. We don't lecture him on and on. This is time for him to “get control”.

• He responds best with a calm manner that is free from emotion.

• He feeds off the emotion and then goes into a “counter control” mode.

• We have found that he needs time and space to “get control”. This could be from getting too excited, hyper or from correction.

• OT has been using the weighted vest to help calm and organize on days when he is having a hard time controlling his behavior and energy level.

• At home we used a modified version of the 1 – 2 – 3 Magic System with privilege revocation rather than room timeouts.

Contact Information

Home 555-5555 Dad Work 555-555 ext, 123 Dad cell 555-555-5555 E-mail: emailaddress@something.com Mom Work 555-5555 Any Other Important Contact Information Such As Emergency Contact, Doctor, Therapist, etc.

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