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Running head: CASE STUDY SAMMY

Case Study: Sammy Yara Bezgina, Megan Campbell, Jessica Fong, Gerilynn Gobuyan, Meredith Petrillo, & Gayle Young Touro University Nevada

CASE STUDY SAMMY Client Participation in Occupational Areas Sammy is a 22-month-old male with low tone, cortical vision impairment (CVI), and infantile spasms, making it difficult for him to participate in meaningful occupations without moderate (Mod A) or maximum assistance (Max A). Sammys occupational areas of play,

activities of daily living (ADLs) and instrumental activities of daily living (IADLs) are usually only completed if one of his parents helps to facilitate the activity. The most significant area of occupation in Sammys life right now is play. He enjoys seeing bright lights and is able to visually track bright lights. He enjoys his favorite toy, a brightly lit toy train, that also makes noise. Sammy enjoys playing with his train toys and other bright toys in supine or prone. He also welcomes auditory and vestibular input, such as hearing music and being pushed on a swing. In regards to ADLs, Sammy enjoys eating and tolerates eating with a bottle or being spoon-fed. Sammy has adaptive equipment in his home which includes a bath chair, a wheelchair/stroller, and a stander. Since Sammy demonstrates poor trunk control and mobility, his IADLs are also affected. He cannot roll or move around without receiving Mod A or Max A. In resting position, Sammys hands are in a fisted position with thumb adduction. Since Sammy is 22-months-old, the occupational areas of work and leisure are not applicable. Most of his educational and social experiences come from interactions with his parents and brother. He is able to babble and he can imitate words such as mama or baba. Upon request, Sammy also likes to blow kisses as a sign of affection. Social participation is achieved through his interaction with Jerry, his four and a half year old brother, as well as interactions with his mom, dad, and therapist. Sammy is fully functional in his occupational area

CASE STUDY SAMMY of sleep. He sleeps six hours a night, getting up intermittently for feeding. According to his parents, Sammy sleeps approximately 12 hours a day. Characteristics of Movements Sammy experiences fluctuating muscle tone in his upper and lower extremities, and as a result has difficulties completing his occupations. Sammy will attempt to work on grasping and releasing if there is food involved. He enjoys sitting in his adaptive chair, which helps him to work on trunk stability and head and neck control. Currently, he is working on hand to mouth coordination during feeding so that he can bring food to his mouth. Sammy is also practicing using a sippy cup, which requires bilateral hand coordination, as well as Mod A to bring the cup

to his mouth. In supported sit, he is able to extend his neck for about 30 seconds to hold his head upright. When placed in prone with elbows propped, Sammy is able to extend his head and visually track bright lights to both sides of midline. Sammy is unable to roll independently, and demonstrates a fisted position with thumb adduction while in a resting state. When toys are placed at midline, Sammy attempts to reach for the toys, but has trouble grasping them. If he receives assistance in grasping the toys, he demonstrates difficulty with voluntary release. Sensory Integration and Self-Regulation Issues According to Keshner and Cohen (1989), testing the functionality of the vestibular system can help indicate issues related to postural control. Sammy enjoys bright lights, sounds, and vestibular input while playing. This suggests that he is hyporesponsive in a majority of his sensory systems, and enjoys seeking sensory input whenever it is provided for him. Sammys hyporesponsiveness to sensation could also be due to his developmental delays and CVI diagnosis.

CASE STUDY SAMMY The visual system also contributes to stabilizing responses. Sammys cortical vision issues may contribute to his postural control issues. Unexpected feedback interferes with the childs ability to respond appropriately. Therefore, therapy should be aimed at eliminating extraneous stimuli and assisting Sammys parents in planning for a changing visual scene.

Children with visual deficits or who have difficulty compensating for unexpected or novel inputs will benefit from an unchanging environment in the early stages of motor learning (Keshner and Cohen, 1989). Although Sammy is 22-months-old, he is developmentally behind in his early stages of motor learning. Assessment Tools The first assessment that could be utilized is the Developmental Profile-3 (DP3). This assessment is used for children between the ages of birth to 12 years old. This norm-referenced test can help establish Sammys abilities within five domains: physical, adaptive behavior, social-emotional, cognitive, and communication. The assessment is easy for the therapist to take into the home and use with Sammys parents. Although Sammy is developmentally delayed due to his diagnoses, this assessment will allow the therapist to determine Sammys level in many aspects of his life and develop an appropriate intervention (Alpern, 2007). Another assessment that can be used with Sammy is the Infant/Toddler Sensory Profile (SP). This measure is norm-referenced and is appropriate for children from birth through 36 months. The form is filled out by the caregiver and takes approximately 15 to 20 minutes to complete. The SP tests the following categories: general processing related to schedules and routines, auditory processing, visual processing, tactile processing, vestibular processing and oral sensory processing (Dunn, 2002). The SP can determine if Sammy is experiencing low registration, sensation seeking, sensory sensitivity, sensation avoiding, or low threshold in any of

CASE STUDY SAMMY the processing domains. This assessment will be especially important in order to determine if Sammy is having difficulties in other areas of sensory processing aside from his visual impairment. Sammys mother can easily fill out the assessment while the therapist works with Sammy in the home (Dunn, 2002). Lastly, the Hawaii Early Learning Profile (HELP) can be used to identify Sammys needs, track his growth and development, and determine intervention objectives. This is a criterion-referenced assessment for children birth to three-years-old and can be administered

periodically to track the progress of the child. The HELP is divided into seven domains including regulatory/sensory organization, cognitive, language, gross motor, fine motor, social, and selfhelp. Administration of the assessment is done by one or more interdisciplinary pediatric/early childhood specialists (e.g., occupational therapist, teacher) who observe the child in multiple settings; however, the natural environment is preferred (Parks, Furono, OReilly, Inatsuka, Hoska, & Zeisloft-Falbey, 1994). Functional Problem Statements

Sammy is unable to see in grey tone, from distances further than two and a half feet and has issues with depth perception due to his cortical vision impairment.

Sammy is unable to sit independently due to poor trunk control. Sammy is unable to grasp, release or produce in-hand manipulation of objects due to his hands resting in a fisted position with thumbs in adduction.

Sammy is unable to bring food from hand to mouth due to his inability to cross at midline. Sammy is unable to communicate with others due to poor muscular control in his face.

CASE STUDY SAMMY Family Goals Sammys family is very concerned about his future. His family values independence as

they are from an American cultural background. The family would like to see Sammy improve in five major areas. The first goal is to improve Sammys postural control and his vestibular system. Communication is also another area in which his family would like to see change. Sammy is almost 24-months-old; at 24 months, a child should have 25 single words within his or her vocabulary (Case-Smith & OBrien, 2010). Sammy currently babbles and has no spoken words, but can imitate sounds such as mama and baba. The family wants Sammy to have as much of a normal childhood as possible and would like him to be able to play with his older brother, Jerry. As Sammy ages, his family is concerned with his self-help abilities, more specifically feeding. His family would like to see him participate more during the feeding process and be able to feed himself during meal time. Finally, the family is concerned with Sammys visual efficiency. The family would like to help Sammy adjust to his CVI issues and help Sammy improve his vision skills as much as possible. Due to these family goals and concerns, the family is seeking home-based occupational therapy (OT) services. COAST Goals The COAST method of writing goal statements for OT services was designed by Crepeau et al. (Gateley & Borcherding, 2011), with the focus that practice should be client-centered and occupation-centered. COAST is an acronym that considers the client, the occupation, the level of assistance or independence, specific conditions pertaining to the client, as well as the desired timeline in which the goal is expected to be accomplished (Gateley & Borcherding, 2011).

CASE STUDY SAMMY COAST Goal 1: Sammy will visually track a bright toy train in a dark room with Mod A (75% verbal prompting) for at least 15 seconds by June 20th, 2013. Objectives for COAST Goal 1

1. Sammy will play with a lightbox in a dark room using bright colored gel pads (Baker-Nobles & Rutherford, 1995). 2. Sammy will engage in supported sitting while visually tracking a brightly lit up flashing train toy in a dim lit room. Activities for COAST Goal 1 1. Sammy will visually track a bright toy train in a dark room. 2. Sammy will work on feeding techniques while sitting on his mothers lap using a Glow cutlery set. (Swift, Davidson, & Weems; 2008). 3. Sammy will play with high contrast colored LEGO Duplos (e.g., red and yellow) on top of a black-colored board while in supported sitting. 4. Sammy and Jerry will make shapes with Softee Dough of contrasting colors while Sammy is in his stander. COAST Goal 2: Sammy will engage in supported sit with Mod A (50% physical prompting) during bathing, play, and feeding activities for at least 5 minutes by June 20th, 2013. Objectives for COAST Goal 2 1. Sammy will sit with support on the floor with his brother in order to play with toys for at least five minutes with Mod A (50%). 2. Sammy will sit with Mod A in the bathtub for at least five minutes in order to be washed and play with bath toys.

CASE STUDY SAMMY Activities for COAST Goal 2 1. Sammy will lay in prone on a Happy Flyer Tummy Time while playing with his trains. 2. Sammy will play in supported sit and reach for toy trains located off to his right or left side. 3. Sammy will sit in the hammock hung in his backyard and be pushed gently by his parents. 4. Sammy will participate in oral motor exercises (e.g., blowing bubbles) to strengthen his facial muscles while sitting with his mother in supported sitting.

COAST Goal 3: Sammy will learn to grasp toy trains, sippy cups, and food items with bilateral coordination (Mod A, 50% hand over hand assistance) while wearing a thumb abduction splint by June 20th, 2013. Objectives for COAST Goal 3 1. Sammy will grasp a lightweight bright toy train with the help of his thumb abduction splint while sitting on the floor. 2. Sammy will pick up food with his fingers and bring it to his mouth I (50%) of the time. The other 50% of the time, Sammy will receive Min A to facilitate grasping movement or receive help bringing food to his mouth. Sammy will pick up toys and demonstrate hand-to-hand release. Activities for COAST Goal 3 1. Sammy will finger paint with a variety of baby food in order to facilitate thumb abduction. 2. Sammy will lay prone on a Happy Flyer Tummy Time and play with lima beans in a plastic container placed six inches in front of him.

CASE STUDY SAMMY

3. Sammy will stack one inch blocks with hand over hand assistance while in supported sit. 4. Sammy will read a childrens sing-along-book with his brother and his father, while receiving hand over hand facilitation in turning pages and pressing buttons on the book. Treatment Session Utilizing Occupational Therapy Goals and Objectives According to Kellegrow (2008), creating an intervention based off of a family interview and daily occupations of the family helps to create a family-centered approach to therapeutic intervention. According to Part C of IDEA (Case-Smith & OBrien, 2010), all early intervention programs for children under three years of age should occur in a natural setting. Treatment should be in the natural environment and should be as intrinsically motivated as much as possible. In reference to the first COAST goal, Sammy will play with a brightly lit toy train that makes noise to facilitate engagement in play occupation while strengthening core muscles to facilitate postural control during upright sitting. Utilizing a moving toy train with bright colored lights and sounds will help motivate Sammy to visually track the toy. As OT progresses, Sammy will be encouraged to flex his neck while lying supine by showing him a toy; at the same time, the therapist will plantar flex Sammys ankles to stimulate opposed muscles at opposite ends of the body. OT intervention will occur at the same time of day in the same location of the house. When addressing postural control, treatment should occur in a consistent environment to provide reliable and predictable feedback (Keshner & Cohen, 1989). Once postural control has been achieved, the therapist can grade the activity up by treating Sammy in different areas of the home at different times of the day. In reference to the second COAST goal, Sammy will engage in play activities while in supported sit or in prone. The therapist will incorporate various equipment to improve Sammys

CASE STUDY SAMMY postural control and to develop a stable base of support. By engaging in activities with his brother and parents, Sammy will participate in two areas of occupation: play and social

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participation. To help motivate Sammys participation in play, the therapist will utilize Sammys favorite toys and involve his brother, Jerry, in the activity. Sammys parents can help facilitate play time with bubble-blowing activities to strengthen Sammys facial muscles. A hammock swing will be set up in Sammys backyard to provide Sammy with vestibular and proprioceptive input and work on his postural control. Sammys parents will gently move him back and forth while he sits or lies in prone extension in the hammock swing. Lastly, the therapist will address the third COAST goal by creating a personalized spica thumb abduction splint for Sammy. When engaging in play and feeding activities, Sammy will wear the thumb abduction splint to assist in grasping objects. Sammy will engage in a finger painting activity with the therapist, utilizing his fingers or a square sponge to facilitate thumb abduction. To engage his upper body and develop his physical skills as well as muscles for rolling over, sitting, and crawling, Sammy will lie prone on the Happy Flyer Tummy Time while attempting to grasp lima beans located in a plastic container placed six inches in front of him. Sammy will work on grasp and release by stacking one-inch blocks with hand over hand assistance. Utilizing food to intrinsically motivate Sammy will help facilitate his fine motor pincer grasp, as well as increase tone in his thumbs. SOAP Note The problem-oriented medical record (POMR) was developed in the 1960s by Dr. Lawrence Weed to standardize physician and nursing documentation (Gateley & Borcherding, 2011). As part of a client-centered approach to documentation, Weed recommended that the POMR be organized into four sections. Thus, the SOAP note was introduced to define four

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distinct sections: subjective, objective, assessment, and plan. The subjective section includes the clients reports on his or her own problems, needs, and perception of progress. The objective section contains the health professionals observation of the clients performance and the treatment provided. The assessment section is the analysis and interpretation of events reported in the subjective and objective section. Finally, the plan section involves the anticipated frequency and duration of services (Gateley & Borcherding, 2011). Subjective: Sammys mother reports that he is easily engaged with bright colored or musical toys, and enjoys sitting in his adaptive chair. Mom reports that he responds with smiles to verbal cues and changes in tone of voice. Sammy started receiving in home OT services one month ago. Mom also noted that Sammys favorite toy is a light-up, colorful train. Objective: Sammy engaged in 1 hr of OT at home, focusing on postural control, visual-motor skills, and fine motor skills (grasp, in-hand manipulation, and shifting). Preparatory activity (oral praxis) included a bubble-blowing game. This was followed by a self-feeding activity, while standing and using adaptive chair. Visual-Motor: Sammy was placed in his stander while playing Softee Dough with Jerry. He tolerated being in his stander for 8 minutes. Sammy especially liked the red and blue Softee Doughs and enjoyed touching and examining the dough. Postural Control: Sammy required Mod A to lie prone on his Happy Flyer Tummy Time for 8 minutes. He demonstrated fair postural control and energy levels required for reaching and grasping his bright toy trains and displayed Min fatigue. Sammy required Min prompts and cues with Mod A when blowing bubbles in supported sit with his mother.

CASE STUDY SAMMY Grasping: Sammy spent 20 minutes in adaptive chair during feeding. With HOH A, Sammy demonstrated I reaching for raspberries 4 out of 6 trials. Sammy struggled but showed gradual improvement. Sammy was able to grasp raspberries I 3 times out of 6 and bring raspberries to mouth with Mod A. Sammy was able to maintain balance, showed good stability and postural control while sitting in adaptive chair. Sammy

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showed good motivation and interest to continue with the activity and expressed his joy by laughing and smiling. Sammy showed interest and joyfulness during feeding. Sammy likes food and shows good motivation to participate in activities related to self-feeding. Assessment: Sammy had problems with grasp and release, as evidenced by fisted hand position. He wears a thumb abduction splint to facilitate functional grasp. Sammy has difficulty crossing midline as evident by the child not being able to bring food to his mouth. Fluctuating muscle tone and delayed motor planning impairs Sammys ability to self-feed I. After feeding, Sammy showed improved ability to grasp food with his fingers utilizing thumb abduction splint. Sammy showed better ability to balance himself in the chair while reaching, and showed motivation to I reach and grasp. Sammy attempted to bring food to the mouth. Sammy has a good potential to follow tactile facilitation and cues. Sammy demonstrates good potential to improve his fine motor skills and postural control through participation in similar play activities. Plan: Sammy will meet with OTR @ home 2x/wk, 1 hr/session over 2 mos to address selffeeding, postural control, and visual motor skills. Sammy will work on sitting, grasping, and holding a sippy cup and bringing it to his mouth. Sammy will work on FMC by playing with different-sized toys in his play area. Sammy will work with SLP on communication skills. Sammys family will encourage and motivate Sammy to learn and utilize appropriate skills for ADLs and IADLs.

CASE STUDY SAMMY Post-Discharge Environment It is important to consider the most natural setting for the child when planning the

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discharge environment. As Sammy is only 22-months-old and is currently receiving treatment in his home, the home will continue to be the environment that Sammy spends the majority of his time. Providing consultation to Sammys parents in regards to achieving an optimal level of independence throughout his life is also a crucial aspect to consider. First, Sammys parents will receive information on how to balance and schedule their day in order to create opportunities for intrinsic motivation throughout the day. His parents will receive education on how to provide therapeutic play to their child to facilitate developmental milestones without burning themselves out. Based on his familys schedule and Sammys needs, it is recommended that the OT continue to help organize a schedule for the family where each family member can contribute to therapeutic play and activities thus removing caregiver strain. If need be, parents may be eligible to receive respite care services, and the OT will make recommendations for this if it seems appropriate in the future. Sammys parents will be taught an array of games and play activities that involve the entire family; this will facilitate Sammys independence and foster a more cohesive feeling of being a family. To achieve these goals of independence and cohesiveness within the family unit, Sammys parents will be encouraged to observe Sammy during his OT sessions, and an explanation will be provided to his parents in regards to theoretical models supporting the therapy plan. Sammys family should be integrated into the treatment sessions when appropriate to encourage collaborative play and inclusion within the family. Safety is of the utmost importance when considering pediatric intervention plans. Sammys parents have experience raising his older brother Jerry, and therefore are aware of

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some of the basic safety issues that need to be in place in order to provide Sammy with the safest environment possible. Besides the safety concerns of a typically developing child, additional safety measures must be in place for Sammy. One of the most critical potential safety hazards for Sammy is his low vision due to his CVI. Sammys parents must be aware of potential hazards that a typically developing child would be able to see and must make sure that Sammy is safe from these hazards. Once he becomes more mobile and independent in locomotion, Sammys parents will have to be aware of the layout of their household, and make sure that Sammy does not bump into furniture. They will also have to ensure that Sammy does not have access to sharp objects or items that might burn, puncture, or otherwise injure Sammy. In concurrence with safety precautions, it will be essential to maintain Sammys dermatological function splint care, and an application schedule will be discussed and approved with parents. In order to keep Sammys natural environment conducive to locomotive patterns, surfaces and furniture should be sturdy in nature and in place for Sammy to hold on in order to facilitate creeping and walking. Furniture may need to be rearranged to promote the most movement and safest environment for Sammys limited vision. Musical and visually stimulating toys are recommended to increase his motivation to creep and engage in supported walking. At home Sammy will be able to participate more effectively in social interactions if he can see, hear, reach and touch therapeutic items such as symbolic representations of letters, toys with different textural components and a communication board. These items should be accessible and within reach, and Sammy will be encouraged by family members to use them as often as possible. Sammys brother Jerry should participate in play activities as much as possible, which can be therapeutic in nature as play can be a modality for change to the young child. Sammys

CASE STUDY SAMMY brother is a typically developing child, and will help Sammy with his social skills by modeling socially appropriate behaviors. Occupational therapy should be family-centered and focus on games and activities that the two siblings can enjoy doing together. All future interventions should be as intrinsically motivating as possible for Sammy. Interventions should also be done with objects and items that the family has in the home as much as possible. Simple exercises, such as blowing cotton balls with straws across the room

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or playing a cup game with marbles, could help address Sammys fine motor issues and cortical vision deficits. The occupational therapist will continue to facilitate these interventions in order for Sammy to be as independent as possible throughout his life. Recommendations Sammys parents and therapists should begin to plan the transition from home to a special education or regular preschool classroom within the next 12-15 months. The focus should emphasize developmental milestones and pre-academic skills in order to be able to participate in the preschool environment. Sammys service coordinator for his Individual Family Service Plan (IFSP) will help manage the transition from home-based early intervention to the school environment when Sammy is old enough. Sammys parents should keep the play environment simple and uncluttered. This will also ensure that Sammy can safely explore his environment without being injured. Sammys parents should ensure the home is free of obstacles and any harmful household products that Sammy may not be aware of due to his CVI (Good, 2001). Additionally, it is recommended that the family use different lighting situations to reach optimal conditions for viewing. Items that Sammy uses on a regular basis should be safe, hygienic, high contrast, and easy to view.

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Although Sammy has not experienced spasms for the last six months, it is recommended that he begin a medication treatment consisting of oral prednisone (liquid form) if the spasms were to reoccur. Historically, daily injections of adrenocorticotropic hormone (ACTH) have been the first choice of treatment for infantile spasms (Kossoff, Hartman, Rubenstein, & Vining, 2009). However, ACTH has been associated with adverse side effects and costly. Oral prednisone is a better alternative to ACTH due to its affordability and is less invasive than daily injections (Kossoff et al, 2009). To keep Sammy on a consistent medication schedule, his parents should use a visual schedule to track his medication times and medical appointments. This will ensure he is receiving consistent and proper medication to treat his spasms, and will contribute to his performance during OT. Since Sammys spasms and CVI are a result of a neurological defect and damage to his nervous system, his parents should be diligent about keeping appointments with a pediatric neurologist, pediatric ophthalmologist, as well as a developmental pediatrician. Sammys parents should track his progress with the medications he takes for his spasms. Further home-based OT treatment is recommended to prepare the child for preschool transitioning and to help Sammy reach developmental milestones. A typically developing child will know approximately 25 words by the time he or she reaches 22 months (Case-Smith & OBrien, 2010). Since Sammy is only babbling and attempting a couple of words, communication is another aspect of significance and concern with Sammy. According to Kaiser and Roberts (2011), delayed speech and language are early indicators of developmental deficits that may impact future academic and social success. Early intervention should focus on prelinguistic forms of communication to increase the childs communication abilities if the child demonstrates a need for this form of therapy (Kaiser & Roberts, 2011). Activities such as blowing bubbles and mimicking facial expressions provide physical and sensory input prior to

CASE STUDY SAMMY language stimulation. Sammy might be demonstrating inability to communicate due to poor musculature of his muscles of facial expression (Kaiser & Roberts, 2011). Strengthening these

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muscles will aid Sammy and his family in their overall communication goals for him. A speech language pathologist and an augmentative and alternative communication specialist (AAC) can provide recommendations to evaluate communication strategies to incorporate into Sammys daily routine. A vision specialist can assist Sammy in implementing visual interventions, especially as Sammy is preparing to transition into school. Sammys parents and brother should continue to encourage and help Sammy in achieving goals and milestones associated with his ADLs and IADLs. Sammys service coordinator for his IFSP can help to coordinate the therapeutic interventions from his vision specialist as well. Sammy should receive an IFSP, part C of IDEA. Interventions should occur in a natural environment, identify family priorities, and provides timely, comprehensive, and multidisciplinary evaluations. The IFSP is a written plan that delineates families plans and provides services, and is reviewed every six months, with an annual reevaluation. A service coordinator is assigned to oversee and manage the implementation of the IFSP. Transition procedures are implemented through three years of age. As the family is the main priority in this intervention, preparing Sammy for preschool and discussing the IFSP is relevant and appropriate. Justification for Treatment Self-care activities are one of the primary goals for early intervention as children are learning the necessary skills in order to gain independence from their parents in their ADLs. According to Kellegrew (1999), participation in self-care activities depends on two primary components: ability and opportunity. The opportunity to perform self-care is as important of a

CASE STUDY SAMMY contributor to learning self-care as the ability to perform the task. For very young children, the saliency of the environment and developmental milestones are key features in developing

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opportunities to perform these tasks (Kellegrew, 1999). In early intervention, it is vital to create therapy goals centered on family values and goals that utilize the childs intrinsic motivation. Swift, Davidson and Weems (2008) also encourage active learning and intrinsic motivating and rewarding stimuli. Another justification for the inclusion of the family in the overall treatment according to Humphrey, Jewell, and Rosenberger (1995) is the dynamical systems perspective. This perspective correlates with various fine motor skills and emphasizes creating opportunities for practice when the therapist is not present. Important factors to consider when facilitating fine motor skills include object size, ease of instructions, and having an adult model the skills (Humphrey, Jewell & Rosenberger, 1995). By having Sammy work on grasp and release of various objects with a skilled therapist, he will be able to model the correct grasp patterns. After his therapeutic sessions, Sammy should be given multiple opportunities to practice these skills at home with his family. Sammy has better opportunities to achieve future independence and success in the goals that have been set by his family if he is given these opportunities. To aid Sammy in his gross motor skills, it is important to consider the vestibular systems influence on postural control (Keshner & Cohen, 1989). There is consensus in the literature that responses to whole-body destabilization are influenced by visual, proprioceptive, and vestibular input (Keshner & Cohen, 1989). By utilizing a Happy Flyer Tummy Time with support from the therapist, Sammy can work on postural control while receiving vestibular stimulation. When treating a child with postural instability, it is important to assist the child in planning a motor response pattern through prior information about task demands. Additionally, motor response

CASE STUDY SAMMY should be supported through graded stimulation of functionally opposed muscles. By adding a toy for Sammy to reach and grasp, his feedback loop will be enhanced due to specific sensory input (Keshner & Cohen, 1989). The therapist who develops interventions for a child with CVI should present the child with different options and be cognizant of selecting safe, appropriate, and interesting stimuli (Swift, Davidson, & Weems, 2008). Children with CVI may have a wide range of visual

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impairments including fields of visual loss and fluctuations in overall performance. Interventions should simplify the visual environment while avoiding extraneous stimuli and visual bombardment. Swift, Davidson, and Weems (2008) also suggest decreasing brightness and glare in the therapeutic environment to avoid light sensitivities. In Sammys case, therapy could be conducted in a dim lit room. The therapist will use the light up train, as this is Sammys favorite toy, which will stimulate Sammys visual system. Using toys that children are familiar with provides therapeutic benefits since children attend to these objects more positively (Swift, Davidson & Weems, 2008). Interspersing therapy in different lighting environments will assist Sammy in his occasional fluctuation in visual performance due to his CVI.

CASE STUDY SAMMY References

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Alpern, G. (2007). Developmental Profile 3. Los Angeles, CA: Western Psychological Services. Baker-Nobles, L., & Rutherford, A. (1995). Understanding cortical visual impairment in children. American Journal of Occupational Therapy, 49 (9), 899-903. doi: 10.5014/ajot.49.9.899 Case-Smith, J., & OBrien, J. (2010). Occupational therapy for children (6th ed.). St. Louis, Missouri: Mosby Elsevier. Coppard, B.M., & Lohman, H. (2001). Introduction to splinting: A clinical-reasoning and problem-solving approach (2nd ed.). St. Louis, MO: Mosby. Dunn, W. (2002). The infant/toddler sensory profile manual. San Antonio, TX: The Psychological Corporation. Gateley, C.A., & Borcherding, S. (2011). Documentation manual for occupational therapy: Writing SOAP notes. (3rd ed.). Thorofare, NJ: Slack Inc. Good, W. V. (2001). Development of a qualitative method to measure vision in children with chronic cortical visual impairment. Transactions of the American Ophthalmological Society, 99: 253269. Humphrey, R., Jewell, K., & Rosenberger, R.C. (1995). Development of in-hand manipulation and relationship with activities. American Journal of Occupational Therapy, 49(8), 763771. Jackson, L. L. (2007). Occupational therapy services for children and youth under IDEA. Bethesda, Maryland: AOTA. Kaiser, A. Roberts, M. (2011). Advances in early communication and language intervention. Journal of Early Intervention, 33(4), 298-309.

CASE STUDY SAMMY Kellegrew, D. (1999). Creating opportunities for occupation: An intervention to promote selfcare independence of young children with special needs. American Journal of Occupational Therapy, 52(6), 457-465.

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Keshner, E. & Cohen, H. (1989). Current concepts of the vestibular system reviewed: The role of the vestibulospinal system in postural control. American Journal of Occupational Therapy, 43(5), 320-330. Kossoff, E., Hartman, A., Rubenstein, J., & Vining, E. (2009). High-dose oral prednisolone for infantile spasms: An effective and less expensive alternative to ACTH. Epilepsy and Behavior, 14(4), 674-676. Parks, S., Furono, S., OReilly, K., Inatsuka, T., Hoska, C. M., & Zeisloft-Falbey, B. (1994). Hawaii early learning profile (HELP). Palo Alto, CA: VORT. Swift, S., Davidson R., & Weems, L. (2008). Cortical visual impairment in children: Presentation intervention, and prognosis in educational settings. TEACHING Exceptional Children Plus, 5(4), 2-14.

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