Running head: CASE STUDY 1

Case Study: Pyschosocial Condition

Rachel Csatari

Saginaw Valley State University

CASE STUDY 2

Personal Data and History

K is an eleven-year-old Caucasian male who lives with his parents and two younger

brothers. K is a soft spoken and intelligent child. His preferred activities consist of legos,

reading, animals and swimming. He has a strong dislike for objects with a slimy texture. In

contrast, animals, swimming and Wii Games are motivators for him. Some behavior triggers for

K consist of large crowds and activities that he feels incapable of performing, because he is a

perfectionist. Sometimes he displays unwanted behaviors, including occasional meltdowns, in

which he will often cry. In these situations reassurance helps to calm this behavior.

He enjoys sensory activities that are hands on, and he is willing to get his hands dirty

with substances such as shaving cream, finger paint and play dough. After playing with a messy

material K insists on washing his hands immediately. In addition, he enjoys the ball pit, scooter

boards/ramp, and swinging.

Furthermore, K loves animals and going to the zoo. His family owns a variety of animals

including rabbits and dogs and he shows the rabbits at the local fair every year. K enjoys

outside activities such as Frisbee, throwing a football, jumping rope, blowing and popping

bubbles. In addition, he recently learned how to ride a two-wheel bike independently.

Swimming is another one of K’s favorite activities. He loves playing in any kind of

water and it brings a huge smile to his face. He is talented at swimming and loves going

underwater. He wears goggles and dives under the water picking up objects from the bottom of

the pool. He recently competed in the Special Olympics last year at Saginaw Valley State

University. K is very intelligent and enjoys school; he is currently in the fifth grade.

CASE STUDY 3

Diagnosis

K was diagnosed with autism as a young child. He was developing normally as a toddler

and then started regressing and displaying atypical behaviors around three years of age.

According to Atchison and Dirette (2007), Autism is a developmental disorder with a

neurobiological origin. While the exact etiology is still unknown, it is recognized that the

abnormal characteristics of autism are caused by abnormalities in the function and/or structure of

the brain. Case-Smith (2005) describes Autism as, “… characterized by severe and complex

impairments in reciprocal social interaction and communication skills and by the presence of

stereotyped behavior, interests, and activities (as cited in American Psychiatric Association

2000). Autism is a lifelong disorder with the onset occurring during childhood, typically by

three years of age (Case-Smith, 2005).

At young ages, children with autism will not utilize gestures, eye contact or

verbalizations to communicate (Case-Smith, & Arbesman, 2008). Autism affects many areas of

a child’s life including participation in activities at school, home and in the community (Case-

Smith, 2005; Case-Smith & Arbesman, 2008). Common symptoms of autism include: limited

social interaction, delayed or language deficit, behavioral problems, and sensory-processing

difficulties (Case-Smith & Arbesman).

However, there is wide range of levels in functioning in children with a diagnosis of

autism. According to According to Atchison and Dirette (2007), “Autism is not seen as one

disorder; rather it describes a spectrum of disorders that range in severity of symptoms, onset and

course of development, and presence of features such as cognitive impairment or language delay

(p. 24).

CASE STUDY 4

K functions on the higher end of the spectrum. He has difficulty in social interaction,

avoids eye contact, displays limited use of facial expressions and social gestures and seems to

have difficulty interpreting other individual’s use of these expressions and gestures. His smile is

very unnatural; it is as though he was taught how to smile. K does communicate verbally,

however, he is often reluctant to talk, and only uses language when something is extremely

important to him. His voice is high and he has a lack of expression in his speech patterns. He

prefers to play alone and has difficulty understanding how to appropriately relate to peers.

He also displays difficulties in sensory processing and integration. This is very common

in children with autism. These problems were noted through the administration of the Sensory

Profile and through observation throughout camp. He has difficulty in modulation of sensory

input affecting emotional responses and modulation of visual input affecting emotional responses

and activity level according to the Sensory Profile. The assessment also indicated that he has

poor registration of sensory input. It was noted throughout observation that he craves sensory

input by his choices during sensory time during camp. K would spend a great deal of time in the

ball pit and also liked the scooter board ramp as well as swimming.

Moreover, he has difficulty with transitioning between activities and he has very rigid

and set routines related to bedtime and personal hygiene. K has difficulty regulating his emotions

and displays emotional liability; he will sometimes cry in situations such as transitioning from a

preferred activity to a non-preferred activity. Lastly, K displays some clumsy and awkward

movements when engaging in gross motor activities and is developmentally behind typically

developing peers of his age. This was observed during camp, when K was engaging in activities

with the peer mentors. K also engages in some repetitive body movements (stimming); usually

these are movements with his hands or he visually stims on objects or the television.

CASE STUDY 5

Frames of References Used

The frame of reference (FOR) to enhance social participation and sensory integration

frame of reference are both applicable to K’s diagnosis. An intervention approach that

incorporates aspects of both is most beneficial to treat K and strive towards improvements in his

ability to function and participate in the community, at school and in his home.

A Frame of Reference for Sensory Integration

The sensory integration (SI) frame of reference is valuable to direct K’s treatment

because of its overall focus on successful participation in life activities in the home, school and

community. This FOR takes into consideration all sensory systems and structures interventions

that provide the “just right challenge” for sensory integration to occur for each individual.

This frame of reference applies to K because he displays problems in sensory processing

and integration. According to Case-Smith (2005), “For almost 40 years, disturbances of sensory

and perceptual processing have been reported in children with autism (p. 192). He has difficulty

in modulation of sensory input affecting emotional responses and modulation of visual input

affecting emotional responses and activity level according to the Sensory Profile. The

assessment also indicated that he has poor registration of sensory input. It was noted throughout

observation that he craves sensory input by his choices during sensory time during camp. He

would spend a great deal of time in the ball pit and also liked the scooter board ramp as well as

swimming.

In addition, it was noted through observation during camp that K displayed

incoordinated and sluggish movements when engaging in gross motor activities. His skills in

throwing a Frisbee and football were uncoordinated and lower than the peer mentors

participating who were also eleven years old. Therefore, the use of the SI FOR would be useful

CASE STUDY 6

for K in providing a foundation for successful participation by improving his ability to modulate,

discriminate and integrate sensory information from his body and the environment; increasing

his postural control and praxis skills; and further developing his self-esteem and self-efficacy.

A Frame of Reference to Enhance Social Participation

The frame of reference to enhance social participation also applies to K’s case. This FOR

concentrates on helping children increase participation and improve their performance at school,

in the community and at home. According to Kramer and Hinojosa (2010), “This frame of

reference is based on acquisitional and behavioral theories that conceptualize how children learn

to participate effectively in social situations and how to promote development of the skills

necessary for social participation.” (p. 306)

K has difficulty in social participation because of his deficits in use and comprehension

of social expressions and gestures and emotional liability. This FOR would focus on teaching K

skills and strategies in order to help him engage in successful social interaction. For example,

according to Kramer and Hinojosa, some important social habits and routines include scanning

faces to look for expressions and making eye contact while speaking. In addition, this FOR

concentrates on assisting a child in identifying and recognizing emotional states, as well

developing and using strategies to manage emotions during challenging situations. This would

be beneficial for K as he has difficulty regulating his emotions throughout the day, especially

during transitions between activities. By learning strategies and coping techniques to manage

emotions and recognize and respond to the fluctuating emotions of others, K will be able to

increase his successful social interaction with his family, peers and other individuals he interacts

with on a daily basis.

Observation of Evaluative Elements

CASE STUDY 7

The Occupational Therapy Practice Framework Domain & Process 2nd Edition was used

to obtain information evaluating K and to plan his treatment interventions. The following

sections contain relevant information pertaining to K and his situation.

Areas of Occupation

Individuals engage in wide range of life activities including activities of daily living,

instrumental activities of daily living, rest and sleep, education, work, play, leisure, and social

participation (AOTA, 2008). It was important to gather information regarding the past and

present areas of occupation that K has participated in, as well as future areas of occupation in

which he desires to engage.

Activities of daily living (ADLs). K is independent in dressing, eating and feeding,

personal hygiene and grooming, bowel and bladder management, toileting, and functional

mobility. He does not have any difficulties in any of these areas and performs them self-

sufficiently when at home or in the community such as while he was attending Cardinal Kidz

Camp.

Instrumental activities of daily living (IADLs). Due to K’s age he doesn’t yet engage

in many IADLs. However, his family owns several animals and he helps take care of the dogs

and rabbits.

Rest and sleep. During camp, the children participated in a quiet time where they

watched a movie. K quietly rested, but he did not fall asleep. There is limited information

regarding his sleeping patterns at home. He does however, have rigid rituals in his personal

hygiene as reported by his mother in the Sensory Profile. If he is unable to follow these routines,

prior to bedtime, he can become tearful and have difficulty falling asleep.

Education. K attends elementary school. He is currently in the fifth grade.

CASE STUDY 8

Play. K engages in play activities. However, he prefers to play alone. He has difficulty

engaging in pretend and symbolic play.

Social participation. K participates in social settings at school, in the community and

within his home with his family. He has difficulty in interacting with others especially in

unfamiliar settings, which may cause him some anxiety. Because he has verbal skills the

challenge in interaction is due to his lack of desire to use verbal communication and trouble

using and interpreting eye contact, facial expressions and social gestures.

Client Factors

Client factors include intrinsic aspects of the individual addressing values, beliefs, and

spirituality as well as physiological functions of the body systems and anatomic parts of the

body. The following section addresses client factors that are relevant to K’s case.

Values, beliefs, and spirituality. K is a soft-spoken child who is very gentle and kind to

those around him. It is apparent that K loves his family very much and values spending time

with them. In addition, he loves animals and enjoys observing them and taking care of them.

Furthermore, during fine motor time, K fully engaged and completed all of the crafts. It was

evident that K values hard work and precise work. He always did his best and definitely values

perfection.

Body functions. K has intact mental functions of attention and memory. He followed

instructions during fine and gross motor activities throughout camp. He focuses very well and

attends to the different activities, following directions and sequences. However, he does not

multitask very well; during camp, he only focused on one activity at a time.

His emotional functions of coping and behavioral regulation are low. He displays

emotional liability when he is overwhelmed or upset such as during transitions during activities.

CASE STUDY 9

His vision, hearing, vestibular, taste, smell, proprioception, pain, temperature and pressure

sensory functions are intact. K is sensitive to light and has sunglasses that he wears continuously

if outside and it is sunny.

K has good joint mobility and stability, control of voluntary movement and his gait

patterns are typical. He does have slightly low tone and low muscle endurance. He lacks age

appropriate skills in gross motor activities such as throwing a Frisbee or a football. While he

enjoys these activities his eye-hand coordination and movements are not developed to the same

stage as his same age peers.

His voice functions are intact. He is quiet most of the time and only talks if something is

important to him. He speaks in a quiet and high-pitched voice.

Body structures. According to WHO (2001), body structures consists of all anatomical

parts of the body, such as organs, limbs and their components that support body function present

(as cited in AOTA, 2008). K currently has all body structures present.

Performance Skills

According to AOTA (2008), “performance skills are the abilities clients demonstrate in

the actions they perform” (p. 640).

Sensory perceptual skills. K identifies and discriminates between sensations. But K

has impaired ability to modulate and organize sensory input. He displays sensory seeking

behavior (e.g., seeking movement, seeking contact with people and objects etc.) and has

impaired skills in the area of sensory registration (e.g., doesn’t perceive body language or facial

expressions and doesn’t express emotions).

Motor and praxis skills. K coordinates movements to engage in activities. He has

excellent fine motor skills and follows sequenced actions. When engaging in gross motor

CASE STUDY 10

activities he displays some uncoordinated movements such as when running, walking on a line,

throwing a ball and using a scooter board.

Emotional regulation skills. K has difficulty with emotional regulation skills. He

struggles with identifying, managing and expressing feelings when working with others. He

doesn’t identify or acknowledge the feelings of others. He is very kind, and never displays

aggressive behavior or outbursts, but he does exhibit inappropriate emotions including crying

during transitions between activities.

Cognitive skills. K uses actions and skills to plan and manage the performance of

activities. He is able to follow directions with several steps. He can sequence tasks to complete

activities. He does have difficulty with multitasking and becomes very focused on a single

activity.

Communication and social skills. K has impaired communication and social skills.

This is due to his difficulty in interpreting and utilizing social expressions, gestures, and eye

contact. He prefers to play alone and while he will answer questions he does not engage in

conversation with other people. He will only initiate conversation if it is something very

important, or he needs assistance.

Performance Patterns

Performance patterns consist of, “patterns of behavior related to an individual’s or

significant other’s daily life activities that are habitual or routine” (AOTA, 2008).

Habits. K has a maladaptive habit of stimming when he is experiencing too much

sensory input.

Routines. Routines are very important for K. It is common for individuals with autism

to become very set in their routines and to experience anxiety and display unwanted behaviors

CASE STUDY 11

when changes are made to their routine. K’s routines are shaped around the occupations he is

currently engaged in, including school, chores and taking care of the family’s animals.

Roles. K has many roles, which include being a son, brother, student, peer and friend.

Context and Environment

Context and environment refers to a variety of interrelated conditions within and

surrounding the client that influence performance (AOTA, 2008). The following sections

contain information pertaining to K’s previous and current contexts and environments.

Cultural. K is Caucasian American male. He lives with his parents and two younger

brothers. He has lived in several states and his family enjoys taking vacations. His family is

active and enjoys being outdoors, fitness and animals. K is currently in elementary school and

has many opportunities including extra curricular activities such as swimming in the Special

Olympics and participating in Special Riders, a program offering therapeutic horseback riding.

Personal. K is an eleven-year-old boy currently in school. He lives with his family and

is close with them. He loves animals, swimming and spending time outside.

Physical. K lives with his family in a home in Bay City. They have a large yard with

lots of room for the boys to play outside. Another physical environment that K spends a great

deal of time at is his school.

Social. K’s current social setting includes his family, other children at school, and his

teachers. K’s immediate family consists of his parents and two younger brothers. He is also

close with his aunt and uncle and his cousin.

Temporal. K is a young boy in fifth grade at school.

Virtual. It is unknown if K utilizes any virtual contexts.

Process of Occupational Therapy

CASE STUDY 12

The process of occupational therapy describes the course of action therapists use to

provide services to their clients. It includes the evaluation, intervention plan and outcome

monitoring. This course of action is fluid and dynamic and therapists often focus on outcomes,

at the same time constantly adapting and changing the intervention plan as needed (AOTA,

2008).

Evaluation

The evaluation is specific to the client and the setting. It occurs during all formal and

informal interactions with the client. It is “…conducted by the occupational therapist and is

focused on finding out what the client wants and needs to do, determining what the client can do

and has done, and identifying those factors that act as supports or barriers to health and

participation” (AOTA, 2008, p. 649).

Occupational profile. Information on K’s occupational history, and experiences,

patterns of daily living, interests, values and needs was collected throughout camp by use of a

personal history form completed by his parents, observation and conversations with K and his

parents. Problems and concerns were identified relating to K’s ability to perform occupations and

daily life activities including a difficulty in social interaction, emotional regulation, interaction

and playing with others and difficulty engaging in gross motor activities at a chronological age

level.

Analysis of occupational performance. The analysis of occupational performance is

the second step in the evaluation process and includes more specifically evaluating the client’s

assets, problems, or potential problems by collecting and interpreting information (AOTA,

2008). This was completed in a variety of ways for K. He was observed throughout camp

engaging in different activities including sensory time, swimming at the pool, lunch time, group

CASE STUDY 13

time, and fine and gross motor activities in order to assess the effectiveness of his performance

skills. In addition, information was collected via the Sensory Profile, which is a judgment based

parent questionnaire. Information was synthesized from the occupational profile and then after

consideration to identify K’s occupational performance strengths and limitations, goals were

created that addressed K’s desired outcomes.

Intervention

After the occupational profile and analysis of occupational performance are completed,

the next step is intervention process. According to AOTA (2008), “The intervention process

consists of the skilled actions taken by occupational therapy practitioners in collaboration with

the client to facilitate engagement in occupation related to health and participation. (p. 652)

The intervention process consists of three steps: intervention plan, intervention

implementation, and intervention review. The purpose of the intervention plan is to direct the

actions of the therapist. The plan explains the selected occupational therapy approaches and

types of interventions for reaching identified outcomes, which will be discussed later. Creating

goals and identifying the mechanisms for service delivery as well as considering potential

discharge needs and plans are considered during the development of the intervention plan. A

great deal of planning was completed before Cardinal Kidz Camp began. The gross and fine

motor activities were planned to provide the just right challenge for the children. Therefore, the

activities were planned that the children were capable of completing, but still would provide a

challenge.

“Intervention implementation is the process of putting the plan into action” (AOTA,

2008, p. 656). This is done by implementing interventions to alter factors in the client, activity,

context and environment for the purpose of gaining a positive changed in the client’s desired

CASE STUDY 14

engagement in occupation. During camp, OT students were each in charge of planning and

implementing either gross motor or fine motor activities. In addition, we had group time,

sensory time and field trips to the Children’s Museum and Children’s Zoo.

Two fine motor crafts were planned for each day. Crafts were included which

incorporated tasks of coloring, cutting, gluing, painting, manipulating small objects and more.

After the crafts were completed the children were given the option of activities including play

dough, puzzles, basic coloring, and legos.

Gross motor activities consisted of activities such as: obstacle courses, water games,

circle games, and outdoor games at the volleyball pit. Gross motor time either took place in the

gymnasium or outside. The goal was to allow the kids to move around and expend excess

energy while appropriately interacting and working together.

Lastly, intervention review is a continuous process that is constantly occurring as the

therapist interacts with the client. This element of intervention includes: reevaluating the plan,

modifying the plan as needed and determining the need to continuation or discontinuation of OT

services and for referral to other services (AOTA, 2008). Throughout camp it was necessary to

be flexible; we were constantly reviewing and adapting activities. For example, if the children’s

behaviors were becoming too disruptive and unmanageable during gross motor we would cut the

time short and move on to lunch. The lost time would be made up for later during the day.

Types of occupational therapy interventions utilized. Several occupational therapy

interventions were utilized to direct K’s experience at camp based on the desired outcomes,

evaluation data and evidence from observation.

Therapeutic use of self. Therapeutic use of self is an important aspect of K’s treatment.

This includes the therapist using planned use of his or her personalities, insights, perceptions and

CASE STUDY 15

judgments as part of the therapeutic process to encourage the client and make therapy enjoyable

(American Occupational Therapy Association (AOTA), 2008). K is a kind and gentle child,

which makes it easy to use therapeutic use of self when interacting with him. Throughout camp,

focus was placed on reassuring him when he acted apprehensive and providing warning in plenty

of time before transitions. He is often quiet, and it was very fulfilling and exciting to see him

come out of his shell. Two environments that he enjoys are water and animals. When he is

swimming or around animals the real K appears and he exhibits such pleasure and contentment

that he is a joy to interact with. Therefore, while K was interested and excited by animals or

water he was more willing and eager to have a discussion and interact. For example, I would

often ask him questions and point out different animals or suggest that he show other children his

favorite animals or play a game with other children in the pool

Therapeutic use of occupations and activities. Therapeutic use of preparatory methods,

purposeful activities and occupation-based interventions were utilized throughout camp to help

K meet his goals. Contexts, activity demands, and client factors were all considered when

planning the therapeutic use of occupations and activities.

Preparatory methods are methods and techniques that prepare the client for occupational

performance (AOTA, 2008). In the morning when the kids arrived at camp we would meet as a

group and have a “morning meeting”. During this time the children would be counted, and the

ground rules and schedule were reviewed. The use of this meeting time prepared the children for

the day. It helped them know what to expect for the day, and what behaviors were expected

from them. In addition, the schedule was kept on the whiteboard all day. This was to allow the

children to know what activity we were engaging in currently and where we were heading next.

CASE STUDY 16

By knowing what to expect, the children were prepared for the next activity and were more

cooperative.

Purposeful methods are activities that allow the client to develop skills that enhance

occupational development (AOTA, 2008). In addition, purposeful methods often take place out

of context, or the client’s natural environment. During camp, we had an hour sensory session

right before fine motor time. For the duration of sensory time, the door between the pediatrics

lab and the orthopedics lab was opened and the scooter boards, trampoline, crash pad and some

other activities were placed in the orthopedics lab. The children were allowed to engage in any

sensory activities, as they preferred. Some of the favorites included the trampoline and crash

pad, swings, ball pit and scooter boards and ramp. All of these are activities that help the

children develop strength and endurance skills that will enhance their ability to engage in play

and school activities. In addition, they had to take turns with these activities and they were often

participating together in a specific activity.

Occupation-based intervention engages clients in occupations that match identified goals

and take place in the client’s natural environment (AOTA, 2008). Each day at camp we would

have both gross motor and fine motor activities. These activities were planned in advance and

the environment was structured to provide a growth-facilitating environment for the children to

interact, play and take part in camp activities such as a typically developing child would at camp,

while also improving skills that will be utilized in the community, at school, and at home. Each

activity was intended for a reason and addressed specific skills. Gross motor activities targeted

motor planning, strength, endurance, jumping, catching, running, hand-eye coordination etc. On

the other hand, fine motor activities focused on manipulation of small objects, cutting, coloring,

painting, using scissors and writing utensils, dexterity, stringing objects, and grip.

CASE STUDY 17

Education process. The education process has been utilized in K’s therapeutic

intervention. Education was provided to K’s parents by daily journals and also a dialogue when

K was dropped off and picked up.

Occupational therapy intervention approaches utilized. According to AOTA (2008)

intervention approaches are “specific strategies selected to direct the process of intervention that

are based on the client’s desired outcome, evaluation data, and evidence” (AOTA, 2008, p. 657).

Two intervention approaches were chosen to direct K’s intervention based on the results of his

evaluation.

Establish, restore. Because K has not yet developed age appropriate communication and

social skills, emotional regulation skills, motor and praxis skills, and sensory perceptual skills

this intervention approach was used with K to establish new skills and abilities.

Modify. This intervention approach includes the use of compensatory and adaptive

approaches to assist K in participating in daily activities. For example, during camp we utilized

a schedule to keep the children on task and sensory time was included right before fine motor

activities in order to allow the children time to obtain the sensory input they crave before

beginning activities that require focus and attention.

Outcomes

There are several outcomes that were intended to be the end-result of K’s occupational

therapy services. The outcomes, “specify how the broad outcome of engagement in occupation

may be operationalized” (AOTA, 2008, p. 662). These include improvement in occupational

performance, participation, quality of life, and role competence.

CASE STUDY 18

Improvement in occupational performance. Participation in camp had the objective of

increasing K’s social interaction with other children so he would gain the skills and tools to

enable and promote more appropriate play with other children.

Participation. Participation in camp was for the purpose of providing K with increased

engagement in desired occupations, at home and school specifically in social interaction and

play.

Quality of life. Through increase in social interaction and participation and improved

coping skills, the goal was for K to improve his dynamic appraisal of life satisfaction (AOTA,

2008, p. 663).

Role competence. Through participation in camp, and increased engagement in desired

occupations, the objective was for K to increase his ability to effectively meet the demands of his

roles as a son, brother, student, peer and friend (AOTA, 2008, p. 663).

Pharmacological Assessment

K does not take any medications other than his daily multi vitamin.

Treatment Plan

Assets/strengths

o The client’s family provides a very strong support system.

o The client has many opportunities such as competitive swimming and participating in

Young Riders.

o The client enjoys fine motor and gross motor activities.

o The client loves animals.

o The client has a positive outlook and works very hard at completing activities.

Treatment Plan

CASE STUDY 19

K attended Cardinal Kidz Camp Tuesday through Friday from July 17th to August 17th

every other week for a total of three weeks at camp. He attended camp from 9:00 a.m. to 3:00

p.m. However, this treatment plan also incorporates activities we included at camp as well as

some recommended interventions. In addition, the long-term goals extend longer than then

length of camp. Therefore, the treatment plan would be more applicable in a school or outpatient

therapy site.

Problem/STG/LTG/treatment #1

Problem. K has difficulty interpreting and expressing emotional feelings and facial

expressions.

Short term goal. K will demonstrate appropriate emotional regulation when transitioning

between activities, as evident by three or less periods of emotional liability per day within one

weeks.

Long term goal. K will demonstrate appropriate emotional regulation when transitioning

between activities, as evident by one or less periods of emotional liability per day within four

weeks.

Interventions

o Visual schedule: A visual schedule is utilized at camp to assist in transitions and keep

the children informed of what activity they will be moving to next.

o Sensory time is utilized to provide the children with a break, organize, and regulate

their systems, which is calming for them and assists in reducing emotional liability or

outbursts.

o The ball pit will be used specifically with K to provide deep pressure.

CASE STUDY 20

o A cloth swing will be used to provide linear and circular movements

providing vestibular and proprioceptive sensory input.

o Social stories will be used direct K in appropriate behaviors during transitions and

ultimately reward positive behaviors (Case-Smith, Arbesman, 2008).

Problem/STG/LTG/treatment #2 Social/Communication

Problem. K has difficulty initiating conversation and is reluctant to ask for help or seek

assistance.

Short term goal. K will seek assistance, ask for help or initiate conversation when prompted

at least once during the camp day within one week of camp.

Long term goal. K will seek assistance, or ask for help or initiate conversation

independently at least once during the camp day within three weeks of camp.

Interventions.

o Social scripting will be utilized to provide K with visual information and verbal

strategies that will improve his understanding of social situations (National

Association of Special Education Teachers, n.d.)

o The environment will be structured to present challenges for K, and encourage

communication attempts. For example, placing the materials needed for a project

near the child sitting next to him so that K will need to ask for the supplies (Case-

Smith &Arbesman, 2008).

o Peer mentors will be utilized to initiate conversation and interaction with K. For

example, asking K if he would like to also engage in an activity. Or just initiating

conversation and asking K questions during any activity such as fine motor time.

According to Case-Smith and Arbesman (2008) typically developing children can

CASE STUDY 21

increase the social participation of children with autism by initiating social interaction

and acting as models.

Problem/STG/LTG/treatment #3

Problem. K’s gross motor skills are developmentally behind. He exhibits slightly low

muscle tone, muscle strength, and endurance, impaired coordination and balance.

Short term goal. K will demonstrate use of the horizontal bolster swing by propelling

himself with minimal physical assistance for 5 minutes within two weeks.

Long term goal. K will demonstrate independent use of the horizontal bolster swing as

evident by getting on and propelling himself independently for 5 minutes within four weeks.

Interventions.

o Gross motor activities will be utilized to improve K’s muscle tone, strength,

endurance and coordination including obstacle courses with activities such as

propelling scooter boards, jumping on a trampoline, running, jumping, throwing,

bouncing, and kicking balls balls, etc.

o Activities such as balancing on a therapy ball will be utilized to improve K’s core

strength and increase his balance.

o K will practice walking on a balance beam to improve balance.

o K will be taught how to perform the frog walk and have races with other children to

make this a fun task. This will work on improving muscle strength and endurance.

o K will practice the swinging task.

o Music will be utilized during the intervention to provide enthusiasm and

motivation as K practices swinging.

o Verbal reinforcement will be utilized.

CASE STUDY 22

Recommended Treatment Interventions

I have established several recommended interventions that I believe would be beneficial

to K’s situation and improve the outcomes of his occupational therapy interventions. First of all,

education to the parent’s on the condition of autism, as well as techniques and practices that

could be implemented at home. It is important to maintain good communication with the parents

and ensure that interventions introduced in therapy are being reinforced at home. In addition,

advocacy for the client would be important. It would be crucial to inform and assist K’s parents

in obtaining various services such as therapy while at school, childcare and community resources

for support such as blogs and social networks.

According to Lorimer, Simpson, Myles, and Ganz (2002), the use of social stories can be

a successful intervention for children with autism. Their study, “revealed positive and socially

valid results for a home program implemented collaboratively by parents and professionals”

(Lorimer et al., 2002, p. 59). However, they did state a need for additional research in this area.

Case-Smith and Arbesman (2008) also discussed social stories and noted that they “complement

occupational therapy because they apply to an individualized approach to improving targeted

behaviors, and they elicit the child’s active participation (p. 422). These individual stories are

read to the child to provide him or her with direction for expected behaviors prior to an event.

Therefore, I believe that social stories would be an effective intervention to address in therapy

and at home for K. Social stories could be implemented to assist K in transitions and in

completing every day activities. In addition, they could be useful in teaching him social skills by

utilizing the social stories before K enters into a social situation.

According to Case-Smith and Arbesman (2008), social games and play activities with

peers can facilitate social interaction and improve skills such as taking turns, sharing and

CASE STUDY 23

communication. The Clothespin Board Game Kit (occupation-based kit) is recommended for K

to increase his interaction skills while employing fine motor skills, which K enjoys. This kit

includes several board games that are placed in a holder that has plastic strips glued to it. The

games are played like normal games except for clothespins are used as game pieces. Playing

board games with peers would be a good situation for K to improve his social skills. It provides

a structured environment for social interaction. Moreover, In addition, all games would be

appropriate for K to participate in, but the emotion game would be most beneficial because it is

designed to help the players think about and recognize different emotions and the reasons behind

feelings. Gross motor tasks are included in the Dreidal game such as jumping jacks, standing on

one foot and hopping on one foot, therefore, this game would be useful to address K’s difficulty

with gross motor tasks.

Focus would also be placed on teaching K basic coping mechanisms such as taking deep

breaths, counting to ten, taking some quiet time and engaging in sensory activities when he is

feeling upset or anxious. In addition, different types of music will be experimented to see how

they affect K’s performance and if the use of music can be calming for him.

Other Services Involved and Referrals Recommended

This information was limited as the parents only completed a short personal history form.

K attends school so he has a teacher who is involved. But it is unknown if he receives therapy

services at school. It would be recommended that he receive occupational therapy services and

speech therapy services at school if he is not already. Speech therapy would be useful to address

K’s reluctance to use verbal communication and the resonance of his voice, concentrating on

lowering the pitch and raising the volume.

Psychological and social factors and impact on therapeutic intervention

CASE STUDY 24

There are many psychosocial factors that influence K’s condition and impacted his

experience at camp. A large focus of camp was devoted to providing the children a summer

camp experience and facilitating their communication and interaction with one another because

children with autism struggle with interactions and forming and maintaining friendships.

It was obvious throughout camp that the children’s home life affected their frame of mind

and performance at camp. For example, children who did not eat a nutritious breakfast might

come to camp hungry and display their hunger by behavioral outbursts. In addition, many

parents appeared busy, stressed and overwhelmed. This is a typical pattern for parents of

children with disabilities as they have many additional responsibilities. Furthermore, there were

specific parents that displayed a pattern of being late for drop-off and pickup. It was interesting

to note that there were cultural trends in the levels punctuality. Additionally, parents all display

varying levels of interest in our activities at camp. Daily journals were returned with the

children at pickup and only a small number of parents actually chose to respond. All of these

factors influenced the children on a day-to-day basis. Specifically for K, I was impressed by the

interest his family expressed in camp. I received daily responses from his mother in the journals

and she often expanded, letting me know activities in which K was participating in and exciting

events occurring at home so that I could initiate conversation with K.

Furthermore, it was interesting to observe how the children fed off of each other. If one

child began to act out, their behavior often impacted other children’s behavior and resulted in

more behavioral outbursts. The children often argued over simple things such as being line

leader. Therefore, if one child was having a bad day due to personal issues at home such as

stress, not getting enough sleep, lack of nutritious food etc. it could have an effect on everyone

participating in camp. Specifically for K, this did not occur as much as some of the other

CASE STUDY 25

children. Because K often secluded himself from the other children he was not easily influenced

by their behaviors. He never acted as an instigator, and rarely expressed feelings of frustration as

a result of other children’s actions.

In addition, it was noted that the children had difficulty with any change in routines.

During camp a schedule was followed, however, if we deviated from that schedule the children

often displayed unwanted behaviors. Therefore, it was very important for all the children,

especially K, to maintain consistent routines throughout camp. During week two, we went

swimming on Tuesday, followed by the Museum on Wednesday which resulted in Thursday

being a difficult day. Reflecting on this, the children were tired and the inconsistency with

routine definitely affected their behavior and performance. After Thursday to get back into the

swing of things, Friday was a good day. This was especially important with K because routines

were very important for him. Giving him notice before transitioning activities helped him

regulate his behavior and emotions. On the Thursday following the Museum, K did not display

any behavioral outbursts, but instead acted quiet and withdrawn.

Discharge Plan

K attended camp for three weeks from July 17th to August 17th. At the completion of

camp there was a party in which parents and siblings were invited in order to show pictures and

all of the fun activities camp consisted of. The main goal of Cardinal Kidz Camp was to provide

an environment where children with autism could enjoy a fun and exciting camp experience just

like any other typically developing child while strengthening and developing age appropriate

skills. In addition, focus was placed on development of social skills and facilitating the children

in engaging with each other and playing together. K definitely made progress in the three weeks

of camp, and it was rewarding to see him interact more, and display fewer problems with

CASE STUDY 26

emotional regulation and improve in gross motor and fine motor skills. In regards to conditions

that may affect outcomes, the socioeconomic status and financial situation of K’s family is

unknown. But it is known that K’s family is very supportive and family oriented. They were

leaving for a family vacation immediately after the camp party. In conclusion, K was discharged

at the completion of camp and he returned to school in September.

CASE STUDY 27

References

American Occupational Therapy Association (AOTA). (2008). Occupational therapy practice

framework: Domain and process, (2nd ed.). American Journal of Occupational Therapy,

62, 625-683.

Atchison, B. J. & Dirette, D. K. (2007). Conditions in occupational therapy: Effect on

occupational performance (3rd ed.). Baltimore, MD: Lippincott Williams & Wilkins.

Case-Smith, J. (2005). Occupational therapy for children (5th ed.). St Louis, MO: Elsevier

Mosby.

Case-Smith, J., & Arbesman, M. (2008). Evidence-based review of interventions for autism used

in or of relevance to occupational therapy. American Journal of Occupational Therapy,

62, 416–429.

Kramer, P. & Hinojosa, J. (2010). Frames of reference for pediatric occupational therapy (3rd

ed.). Baltimore, MD: Lippincott Williams & Wilkins.

Lorimer, P. A., Simpson, R. L., Myles, B. S. & Ganz, J. B. (2002). The use of social stories as a

preventative behavioral intervention in a home setting with a child with autism. Journal

of Positive Behavior Interventions, 4 (1), 53-60.

National Association of Special Education Teachers (n.d.) Autism spectrum disorder series:

examples of IEP goals and objectives, 1-5.

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