Running head: CASE STUDY

Case Study Jenna Babcock, Justin Christman, Emily Matthews, Gary Pearson, Ian Sande, and Nicole Sellers Touro University Nevada

CASE STUDY Occupational performance Activities of daily living (ADLs)

Zakary requires maximum assistance for dressing and bathing tasks and he is not showing any interest or motivation to participate in these two daily activities. He also requires wearing of a diaper due to his inability to independently manage his bowel and bladder. Due to his minimal self-regulation skills, he has difficulty with self-feeding, sleep routines, play and socialization skills. He has transitioned from a bottle to a straw cup but does not like any wet or soft foods. He does not have any difficulty with functional mobility; he is able to walk, run, and climb on furniture independently. Instrumental activities of daily living (IADLs) N/A Education Due to Zakarys age of 2 years and 7 months, he is not in preschool yet; also, due to his inability to self-regulate and manage his ADLs and social interactions, he would most likely benefit from occupational therapy and an individual education plan (IEP) when in pre-school. Work N/A Play Zakary is not interested in age appropriate toys and has demonstrated decreased play skills. He has difficulty participating in community play groups or park outings with his sister. He does not transition well between activities and once he becomes upset he will have a meltdown lasting up to one hour. He does not interact at all with his sister or any other children his own age.

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Leisure N/A Social participation His mother is very concerned about his decreased social skills with others and would like to see him interact with his twin sister. He demonstrates poor eye contact and minimal response to his name. When he is upset, however, he does call for his Mama and maintains minimal eye contact when engaged in swing activities during occupational therapy sessions. Rest and sleep Zakary currently takes one daily afternoon nap but wakes up several times during the night and his mother has to soothe him with rocking motions. He also taps his head on the edge of his crib to fall asleep and demonstrates adverse reactions to touch. Characteristics of movement, postural reactions, and/or reflexes Zakary demonstrates poor postural control and decreased limb awareness. When placed in the prone position he demonstrates poor control and will squeal followed by a tantrum for an hour. To decrease poor behavioral output, therapists place Zakary on his favorite swing and apply deep compression with heavy input. This routine is done quite often in order to get Zakary to complete tasks of daily living, play, and social interaction. Sensory integration and self-regulation Zakary seeks for proprioceptive and vestibular input to help him with modulation skills. When in the clinic, he performs wrist rotations and high pitch squeals when the therapist requests him to participate in task completion activities. He has a high threshold for arousal level and has difficulty with sensory modulation. He demonstrates hyper-responsiveness to tactile and oral input; however, he responds well to increased movement activities and rhythmic input.

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Therapists work with Zakary on his proprioceptive and vestibular input by having him perform a series of swinging activities, specifically the Lycra swing, along with deep compression followed by tasks involving tactile and oral input. A specific deep compression activity he enjoys is being squeezed by pillows. At home, he sits in a ball pit and flips open books close to his face and bumps into walls or furniture when walking. When placed in his crib, he taps his head on the crib to fall asleep and also has adverse reaction to touch. He walks on his tip toes, does not like to wear socks and shoes, and walks barefoot on rocks. PEOP model The Person, Environment, Occupation, and Performance model (PEOP) is a dynamic model that describes the collaborative nature of the person, occupation, environment, and performance as they influence the human being (OBrien, 2012). The person factors include the physical, social, and psychological aspects of a person. Zakary is a 31 month year old toddler diagnosed with autism who has a twin sister. He requires maximum assistance for dressing and bathing tasks. He demonstrates poor social skills and resists self-feeding of any wet or soft foods. He is not interested in age appropriate toys and demonstrates decreased play skills. Zakary enjoys spinning in circles and flipping open books very close to his face. His family would like him to be more social and play with his twin sister as well as engaging in tasks such as bathing and dressing. Zakary's environmental factors are the physical and social supports and those factors that interfere with his performance. Zakary's physical supports are proprioceptive and vestibular input. The childs social supports are his caregivers, sister, behavioral and occupational therapists, and speech practitioner. The factors that interfere with Zakary's performance are his self-regulation skills. Zakary's occupations are sleep and play. Zakary has most difficulty with self-regulation, adversely affecting all of his occupations.

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The family wants Zakary to improve his self-regulation skills and play with his twin sister. The interventions should be geared towards reaching the family's goals. The occupational therapist should adapt and modify the environment based on Zakary's performance range. This can be done by providing an adequate sensory diet throughout the day to fulfill Zakary's sensory needs. Theories and practice models/frame of reference (FOR) Zakary would benefit the most from Dynamic Systems Theory. This theory would apply to Zakarys interaction among sensory, cognitive, neuromusculoskeletal, and environmental systems. Dynamic systems theory would allow occupational therapists to facilitate a variety of interventions. When developing goals for self-feeding, dressing, bathing, hand skills and play, it is important to focus interventions on his balance and stability. He demonstrates poor postural control when sitting and has limited motor coordination skills, in part because, the foundation for carrying out skillful movements is not well developed. Sensory Integration will also be important in helping Zakary with his occupations. Zakary has demonstrated poor self-regulation skills which are affecting his ADLs. Zakary has an aversion to soft and wet foods and also taps his head on his crib to fall asleep. He walks barefooted on rocks, dislikes wearing shoes or socks, and walks on his tip toes, seeking proprioceptive and vestibular input. He enjoys spinning in circles, looking at books close to his face, and bumping into walls and furniture, using sensation seeking tendencies to help with modulation skills. By introducing Zakary to Sensory Integration he will be able to improve his modulation and praxis skills, and gain an ability to better regulate sensory information. Zakarys increased ability to regulate sensory processing will help him interact with peers and play with age appropriate toys. He will also be able to regulate his increased need for proprioceptive and vestibular input. Zakarys aversion to certain foods may also be remediated.

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Implementing frames of reference, such as, compensatory and psychosocial may also benefit Zakary as his needs see fit. Assessment The Transdisciplinary Play-Based Assessment (TPBA) is a criterion-referenced evaluation which measures a childs cognitive, social-emotional, communication, and sensorimotor skills. The TPBA is used as an observation tool to evaluate the child. The TPBA can be used with children from birth to 6 years of age. The assessment is performed in the childs natural environment to allow for higher levels of play and exploration. Functional problem statements 1. Zakary requires maximum assistance to dress himself due to lack of interest and motivation. 2. Zakary requires moderate assistance in self-feeding due to dislike of soft and wet foods. 3. Zakary requires moderate assistance when sleeping due to waking up multiple times during the night. 4. Zakary requires maximum assistance when playing and socializing with his sister due to the childs inability to communicate and interact with others in an interactive environment. 5. Zakary requires maximum assistance in playing with age appropriate toys due to an inability to plan and manage the performance of an age appropriate activity.

CASE STUDY Caregiver goals

1. Zakary's family would like him to be able participate with moderate assistance in ADLs including dressing, toileting, and feeding. 2. Zakarys family would like him to engage in a higher level of social play with his sister and other children. 3. Zakarys family would like Zakary to be able to communicate his needs more clearly to help prevent negative outbursts and better transitioning between activities. 4. His mother would like to see an increase in play with age appropriate toys and play skills. 5. His mother would like to enhance Zakarys self-regulation skills during sleep routines to allow for a full nights sleep. COAST goals, objectives, and activities 1. Zakary will demonstrate improved self-help skills in feeding and dressing with moderate assistance 3 out of 4 trials within 6 months. 1a. Zakary will pull up pants with moderate assistance 50% of the time within 6 weeks. 1. Therapist will create a video model of donning and doffing different articles of clothing for Zakary to watch and practice dressing. The video can be created through an app, found on a website, or created by videoing Zakary himself getting dressed.

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8 2. Zakary will don a pillow case on feet, with assistance as needed, and partake in a potato sack race through a therapist designed, novel obstacle course to improve self-help dressing skills.

1b. Zakary will self-feed soft and wet foods (such as pudding, bananas, yogurt, oatmeal, jello and applesauce) with moderate assistance 75% of the time within 6 weeks. 1. Zakary will draw in pudding with fingers and create pudding art on paper at table top to reduce sensitivity to soft textured foods. Paint brushes, paper towels and cookie cutters will be provided to use in play and to transfer pudding to paper for pudding art. 2. Zakary will use cookie cutters to cut shapes out of tray of jello to reduce sensitivity to soft, wet foods. Desired food or toys can be placed into the jello to promote finger play. 2. Zakary will participate in daily self-regulation activities in order to improve his compliance with routine-based activities at home as reported by parents within 6 months. 2a. Zakary will utilize a sensory diet in the home environment to prepare for his daily routines with set up assistance and cueing as needed 5 out of 7 days of the week as reported by parents. 1. Therapist and caregiver will establish a bedtime routine with parent/child stretching exercises to give proprioceptive and tactile input

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9 to help with sensory modulation. The routine can consist of stretching techniques, deep pressure exercises, and a bath time routine. This will require the assistance from a caregiver and is to be performed each night before bed. 2. Therapist will introduce the head, shoulders, knees and toes song to Zakary and caregiver to be utilized at home before participating in daily routines. Assistance will be needed in singing the words of the song and modeling body positions to help with coordination and motor planning issues. A video or audio track of the song may be utilized for assistance.

2b. Zakary will engage in structured sensory activities for 5 minutes to promote a calm state and increase attention to task in 50% of trials with minimal cueing in 6 weeks. 1. Therapist will allow Zakary to choose between two swings to swing on for 5 minutes before tx session and between activities as needed to promote a calm state and increased attention. The swings can be of different nature, providing different feedback, such as a Lycra swing for proprioceptive input and a platform swing for vestibular input. 2. Zakary will sit or lay prone on scooter board and use hands and arms to move scooter board and self into a stack of foam blocks (scooter board bowling) to increase proprioceptive input, decrease arousal levels and increase attention. Assistance can be provided to help Zakary with

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10 motor planning and coordination of UE in moving towards the target. The speed, distance from target, size of block target, and amount of impact can be adjusted according to Zakarys preference or need.

3. Zakary will improve purposeful play for greater social participation with peers/therapists/parents while also furthering his communication development 50% of the time with cuing within 6 months. 3a. Zakary will improve on simple game and reciprocal play with toys/stuffed animals in 50% of trials in 6 weeks. 1. Zakary will participate in play with the therapist with sock/finger puppets to increase peer interaction and appropriate communication skills. Play can take place during a calm and attentive state such as on a swing or after participating in a sensory modulation activity. Therapist may need to provide max A in story modeling to engage Zakary in reciprocal play. 2. Zakary will play Twister alternating turns with therapist to increase peer interaction while providing proprioceptive input, increasing bilateral coordination and limb awareness. The rules of the game can be adapted for age, motor skill, and cognitive appropriateness. Assistance in motor planning and coordination for proper placement may be needed. Music may be played during activity to help create rhythm of movement. 3b. Zakary will increase communication by indicating his choice of play activity

CASE STUDY with minimal cueing 75% of trials within 6 weeks. 1. Zakary will be given a choice of two of the play activities to be

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completed that session to communicate his preference as to which he will complete first. If he will not communicate his preference, the therapist will indicate which will be done first and which will be done at a later time. 2. Therapist will create a visual schedule of three play activities to be completed that session and allow Zakary to choose the activity order. Pictures of the three activities will be attached to a board with Velcro for Zakary to arrange in a desired order. If a decision is not made independently, the therapist will arrange the activities providing a visual model of events for Zakary. Treatment plan Zakary will arrive for tx at the outpatient SI clinic and begin participation in scooter board bowling for 15 minutes to provide proprioceptive input, decrease arousal, and increase attention. Next, he will choose between two swings to participate in for 5 minutes as a transition, decreasing arousal and increasing attention. We will then transition to a table top pudding activity involving picture drawing and paper art with fingers and hands for 15 minutes. Zakary will again choose a swing to transition to for 5 minutes. The next 15 minutes will be spent practicing donning a pillowcase on LE and completing an obstacle course potato sack race to improve self-help skills and grasp strength for dressing.

CASE STUDY SOAP note Subjective Zakary entered into tx session energetic, but hesitant to begin therapy. Zakary transitioned through the tx session with varied behavior appropriateness. Objective

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Zakary participated in a 60 minute outpatient OT session focused on improvements in sensory modulation, self-help skills, and appropriate social skills and communication for increased involvement in functional play with a peer. Zakary demonstrated a need for repetitive visual and verbal cues to maintain attention to tasks 75% of the time. He was able to follow 2-4 word command sentences needing physical and verbal cues to make appropriate eye contact. Proper sitting posture was maintained throughout tabletop activities secondary to verbal and physical cues. He is working on using his lateral pinch strength for play and self-care activities. Zakary demonstrates a weak lateral grasp, needing mod HOH A for dressing activities of LE. He demonstrates adequate UE strength but needs mod A in motor planning. Verbal cues were needed 90% of trials to participate in pretend play. Assessment Zakarys poor attention during the tx session limits his ability to participate in functional peer play and social engagement. Limited fine motor strength with fatigue and minimal limb awareness restricts his ability to I perform self-care and ADLs, interfering with developmental milestones and preparation to enter school. Progress of grasp strength is being made with reduced assistance needed during tasks. His focus is progressing during tabletop activities

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reducing the time of transitions by half indicating good potential outcome for goal attainment. Zakary demonstrates improvements in functional use of communication to demonstrate wants and will benefit from continued skilled OT intervention to increase developmentally appropriate communication skills, sensory modulation, and attention to improve occupational engagement, and age appropriate self-care. Plan Continue to treat Zakary 1x/wk. for 60 min sessions for 6 months to increase developmentally appropriate communication skills, self-help skills for ADLs, and decrease amount of verbal cues needed to maintain selective attention during task. Plan to address limb awareness, and trunk strength and endurance with sensory-based activities including peer interactive play. Specific recommendations and post discharge environment Zakary will be discharged to his home setting. It will be recommended that the parents continue using the sensory diet daily. They should continue working on dressing skills and ADLs in home environment, utilizing sensory modulation, arousal and attention exercises beforehand to help Zakary with sensory regulation. There should be a continuation in improving feeding skills, introducing new foods in the soft and wet textures, allowing 10-15 trials with each food before ruling it out of his diet.

CASE STUDY Justification of treatment based on research

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According to Kuoch and Mirenda (2003), the use of social story interventions for young children with autism spectrum disorders benefited and improved to individual changes in routine and social skills as alternatives to problem behaviors. When the social story intervention was withdrawn, reversal of the effect of treatment did not occur and the problem behavior remained low. This intervention would be beneficial for Zakary while learning appropriate communication skills and practicing self-help skills such as dressing and feeding. Since he is near the preschool age, the social stories would help him in the educational settings as well (Kuoch & Mirenda, 2003). Piazza et al. (2002) found that presence of preferred food in combination with nonpreferred food helped participants eat. Interventions for Zakary include his tactile aversions regarding food. Implementing pudding along with other non-preferred foods during interventions could promote him eating more suitable table foods appropriate for his age. Allowing Zakary to play with the pudding, performing multiple activities such as finger manipulation, would allow him to address his tactile defensiveness (Piazza et al., 2002). Inclusion of preferred food into the jello activity would model the ideas of Piazza et al. (2002) to promote eating of soft, wet foods. Amos (2013) looked at autism and the research concerning the roles of rhythm and timing in regard to perception and coordination of different types of sensory information. Attending to rhythm and timing may offer new, more insightful ways to respond to experiences and social interactions (Amos, 2013). Wimpory et al. (2007) (as cited in Amos, 2013) found interventions that can be used to overcome social timing issues and build a scaffold for emergence of communication and language using Musical Interaction Therapy. Based on

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reports by parents of children and some adults diagnosed with autism spectrum disorder (ASD), several intervention strategies were presented. Strategies such as: emphasizing reciprocal relationships; supporting exploration of preferred interests and expand them in directions that others can share; valid practice in meaningful and typical experiences; dynamic systems encouraging flexibility and support of experiences with different solutions to a task for adaptation skills; creation of safety and reduced anxiety using techniques to relax the body and mind with deep breathing, yoga and mindfulness; music, rhythm and dance to explore emotions and scaffold communication; and exploring adjustments to environment, interactions and selfregulation to enhance praxis are suggested for this population (Amos, 2013). Interventions for Zakary include singing Head, shoulders, knees, and toes as part of his sensory diet to help decrease his arousal and increase his attentiveness to prepare him for activities. Movement based activities such as Twister can be utilized to work on social timing and communication issues for Zakary as well.

CASE STUDY References

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Amos, P. (2013). Rhythm and timing in autism: learning to dance. Frontiers in Integrative Neuroscience, 7(27). doi: 10.3389/fnint.2013.00027 Case-Smith, J. (2010). Occupational therapy for children (6th ed.). St. Louis, Missouri: Mosby/Elsevier. Kuoch, H., & Mirenda, P. (2003). Social story interventions for young children with autism spectrum disorders. Focus on Autism and other developmental disabilities, 18(4), 219227. OBrien, J. C., & Hussey, S. M. (2012). Models of practice and frames of reference. In K. Falk & J. Gower (Eds). Introduction to occupational therapy (4th ed., pp. 136-137). St .Louis: Mosby. Piazza, C. C., Patel, M. R., Santana, C. M., Goh, H. L., Delia, M. D., & Lancaster, B. M. (2002). An evaluation of simultaneous and sequential presentation of preferred and non-preferred food to treat food selectivity. Journal of Applied Behavior Analysis, 35(3), 259-270.