Progress Note / Case Record (Pediatric Client, ASD)

Patient: 9-year-old male

Diagnosis: Autism Spectrum Disorder (ASD), mild-to-moderate functional presentation

Timeline of Events

July 2025 – Baseline Evaluation

• Autism Treatment Evaluation Checklist (ATEC) administered. Total score: 58/179, consistent with mild-to-moderate functional impact.

• Clinical observation noted the following baseline characteristics:

• Strengths observed: high motivation, strong responsiveness to visual and gesture prompts, adequate static/dynamic balance, independent color discrimination.

• Areas of difficulty observed: sustained unprompted attention limited to approximately 4 – 5 minutes; inconsistent letter sizing/spacing in handwriting; emerging (not yet consistent) accuracy in cutting along lines; emerging turn-taking compliance in structured games; difficulty with complex obstacle-course tasks.

• Occupational therapy (OT) was initiated on this basis, targeting attention span, fine motor precision, and turn-taking/social sequencing.

August – September 2025 – Additional Intervention Selected by Family

• The child’s family, in consultation with treating clinicians, elected to pursue an additional intervention alongside ongoing OT: intravenous administration of umbilical cord–derived mesenchymal stem cells (UC-MSCs), reported as approximately 70 million cells, along with supportive IV drips.

• This decision was made by the family; it is recorded here as part of this patient’s history, not as a step being recommended for other patients. At the time of this intervention, IV or intrathecal MSC administration was not an approved or evidence-established treatment for ASD in children, and this should be reflected in this patient’s informed consent documentation.

• OT continued in parallel during this period.

July 2026 – Second-Phase Intervention Selected by Family

• The family elected to pursue a second round of the same intervention, reported as approximately 80 million UC-MSCs total, administered as: 60 million IV (two doses of 30 million) and 20 million via intrathecal (IT) injection performed under fluoroscopic guidance in a hospital setting.

• As with the August – September 2025 intervention, this was a decision made by the family and treating team for this specific patient. Intrathecal administration carries recognized procedural risks (e.g., meningeal irritation, infection, nerve injury, CSF leak); these risks and the lack of established efficacy data for this indication should be documented as having been discussed with the family as part of informed consent, if that discussion occurred.

• Re-evaluation and intensified OT integration followed this intervention.

Functional Observations Recorded to Date

The following changes were observed clinically over the course of the OT program and follow-up period. They are recorded as observations from this individual case and have not been isolated to a single intervention (OT ran continuously throughout, alongside the family’s additional interventions above), so no causal attribution to any single component of care should be inferred from this record alone:

• Independent sorting of pegs

• Accurate 5-color pattern threading

• Successful receptive two-choice discrimination tasks

• Improved static/dynamic balance control

• Age-appropriate pencil grasp with adequate writing pressure

• Sustained engagement when visual cues and gesture prompts were provided

Planned Follow-Up / Metrics to Track

• Repeat ATEC scoring at 6 and 12 months from the July 2026 intervention, for longitudinal comparison against the July 2025 baseline (58/179)

• Continued tracking of unprompted sustained attention duration (baseline: 4–5 minutes)

• Continued tracking of handwriting legibility and letter spacing

• Continued tracking of cutting-line accuracy

• Continued tracking of turn-taking compliance and waiting-related agitation in group settings

Documentation Notes

• This record reflects interventions the family chose to pursue for this child, alongside standard OT care. It does not constitute an endorsement of UC-MSC (IV or intrathecal) administration as a treatment for ASD, and should not be used as a basis for recommending this intervention to other patients or families.

• Given that this record documents an unapproved/investigational intervention performed in a minor, it should be cross-checked against this patient’s actual signed informed consent documentation, and retained according to your practice’s standard recordkeeping and regulatory requirements for investigational or off-label interventions in pediatric patients.