In the context of Early Childhood Special Education (ECSE)—especially when supporting children with Intellectual Disability (ID)—a well-structured case history provides essential information for assessment, individualized planning (IEP/IFSP), and ongoing intervention.
Here are the core components of a Case History:
1. Identifying Information
Child’s full name
Date of birth and age (chronological and developmental)
Gender
Address and contact details
Language(s) spoken at home
School/center details (if applicable)
2. Referral Information
Who referred the child (parent, doctor, anganwadi worker, teacher)
Date and reason for referral
Presenting concerns (e.g., speech delay, behavioral issues, developmental delay)
3. Family Details
Family composition (parents, siblings, caregivers)
Education and occupation of parents
Socioeconomic status
Any family history of disability or mental health concerns
4. Prenatal, Perinatal, and Postnatal History
Prenatal: maternal health, infections, medications, stress, nutrition, alcohol or substance exposure
Perinatal: type of delivery, gestational age, birth weight, APGAR score, NICU admission
Postnatal: milestones, feeding, immunization, neonatal illnesses (e.g., jaundice, seizures)
5. Developmental Milestones
Age of achieving:
Gross motor (sitting, walking)
Fine motor (grasp, hand use)
Language (babbling, first words)
Cognitive and play behaviors
Social-emotional skills (smiling, response to name)
6. Medical History
Current or past illnesses (e.g., epilepsy, recurrent fevers)
Hospitalizations or surgeries
Medications (ongoing or discontinued)
Vision and hearing check-ups
7. Educational History (if applicable)
Early intervention services
Preschool or day-care experience
Performance in group settings
Special services received (speech therapy, OT, physiotherapy)
8. Social and Behavioral Observations
Interaction with peers and adults
Play patterns (parallel, associative, imaginative)
Temperament
Challenging behaviours (if any)
9. Communication Profile
Receptive and expressive language
Gestures or signs used
Use of Augmentative and Alternative Communication - AAC (if any)
Echolalia or stereotyped speech
10. Functional Skills / Activities of Daily Living (ADLs)
Toileting
Eating and feeding
Dressing
Sleep patterns
Self-help abilities
11. Strengths and Interests
What does the child enjoy?
What motivates the child?
Specific talents (e.g., music, puzzles)
12. Parent/Caregiver Concerns and Expectations
Parent’s understanding of the child's condition
Family’s goals for the child
Cultural beliefs or practices influencing intervention
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