Ben: 4 years old 👦🏻
Occupational Deficits:
Evaluation Tools:
Intervention Approach: Establish/Restore
Outcomes:
Performance Skills:
Client Factors:
Context/Environment:
Performance Patterns:
Process Skills: Ben has difficulty with sequencing which is shown in his refusal to eat. He also has difficulties with initiating tasks which can be seen with his feeding and social interactions.
Social Interaction Skills: Ben does not approach or start feeding tasks, or interactions with peers. He lacks the ability to take turns since he is slightly behind socially. Ben also has a hard time speaking to others, due to his language barrier which inhibits his ability to have social interactions.
Cultural: Family is from Costa Rica and immigrated to the U.S for treatment. Mother speaks limited English.
Personal: 4 year-old boy requires increased social and fine motor skills to attend Kindergarten next year.
Temporal: Ben is at the stage of life where he should independently eat, interact in play, and develop age-appropriate fine motor skills. His condition did not allow him to have typical feeding, motor, or sensory opportunities.
Virtual: Ben's mother uses her cell phone to translate during Ben's medical appointments.
Physical: Ben and his mom live in an apartment with the mother's cousin and his wife.
Social: Limited supports due to not having friends or family in the area and feeding and fine motor expectations.
Habits: Ben shys away from social situations with his peers.
Routines: Ben's mom is helping him establish a daily routine including basic ADL's (dressing, bathing, oral hygiene).
Rituals: Ben attends Roman Catholic mass with his mother every Sunday.
Roles: Son with developmental delays regarding feeding, fine motor, and social interaction; future student.
Values: Family and heritage are very important to Ben and his family. His Costa Rican heritage plays a large role in his day to day life.
Develop routines/mealtime structure: (Hye Ran Yang, 2017)
Reducing liquid consumption outside meals
Consistent eating locations
Washing hands and face signals that mealtime is about to start and can also be integrated into his routine.
Oral exploration:The use of a vibrating toothbrush to promote sensory desensitization. The expansion of Ben's palette by offering variations of food textures, temperatures, smells already acceptable, therefore, decreasing his pickiness during meals (Dickinson, 2017).
Food chaining: Process in which a preferred and familiar food is used to bridge to something new. This process includes making small changes to foods they already accept. Examples include dipping a preferred food into a new food, serving the food item differently, and/or trying new foods at snack time to lessen the pressure (Hye Ran Yang, 2017).
Sensory motor activities & games: Interaction/play in developed sensory bins to desensitize Ben's sensory system. Proprioceptive and vestibular input may have a calming effect on Ben.
Models/Frame of References:
Establish participation in social situations appropriately via power cards. This acknowledges the child's interests (i.e., character/superhero) and uses it to facilitate appropriate behaviors in various social situations that the child may be lacking. Each card has a picture of the character along with that "character advocating for the correct behavior" (Case-Smith, O'Brien, 2015). Through this approach, Ben will be better prepared to attend school in a year.
Fine motor skills for meal times: This can be accomplished by developing the pincer grasp necessary for finger feeding. A way to work on developing this is by putting finger foods into a muffin tin so that he must use his fingers to get the food out. To work on grasping utensils, the OT can work with Ben on scooping with a spoon, small foods or practicing with small toys.
Fine motor skills during play:
This can be encouraged through puzzlles, stringing beads, painting, and engaging in tasks the child enjoys.
Developmental: The developmental FOR is based on the sequential development and behaviors influenced by the mastering of the prior level of development. This FOR includes 6 adaptive skills: sensory integration, cognitive, dyadic interaction, group interaction, self-identity, and sexual identity (Creek, 2014) Ben's delay in food intake caused deficits in sensory integration and fine motor skills.
Beliefs: Ben and his family hold strong family beliefs. And strong beliefs that education is important.
Clinical Observation: The OT will examine Ben's oral motor patterns and oral structures. Additionally, the OT will view Ben eating a snack or meal with his mom. This will give the OT insight into the context of feeding such as social interactions, food preferences, verbal and non-verbal cues, fine motor grasp, etc.The Test of Playfulness (Skard & Bundy, 2008) will assess Ben participating in play for 15 minutes and observations will also include fine and gross motor occurances.
Battelle Developmental Inventory, 2nd Edition:
This assessment will provide a comprehensive developmental overview and addresses 5 domains which include adaptive, personal-social, communication, motor, and cognitive (Newborg, 2005). The score of this assessment will give the OT a better understanding of Ben's problem areas.
Child Oral and Motor Proficiency Scale (ChOMPS): A caregiver-report measure that assesses eating and other related skills in children from 6 months- 7 years of age (Pados, Thoyre, & Park, 2018). This scale will be translated and if possible, given to Ben's mom to complete prior to the evaluation beginning.
References:
Long Term Goals:
Initial Interview: The OT will gather information via open-ended questions where Ben's mom can express her concerns. The OT will inquire about Ben's current feeding practices, mealtime and play routines, cultural norms, social rules, and developmental history (Case-Smith, O'Brien, 2015). Inquiring about past strategies may be helpful in figuring out potential next steps. If available, a bilingual OT who speaks Spanish is preferred. If one is not available, his OT should acquire resources to bridge the language barrier gap.
Eating/Feeding
Social/Play Skills
PEOP model (Person, Environment, Occupation, Performance). (Willard & Schell, 2014)This model is fitting for Ben since he is a product of his environment and performance. Ben has limited experience with peers outside of his family leading to his lack of social play and interaction. Due to Ben's condition, he was unable to begin exploration and food intake orally until recently delaying sensory integration.
Temperament/ Personality: Ben has a loving personality and is very close to his mom. Their language barrier prevents him from being social with peers his age.
Strengths: His social interaction with his mother and cousin are normal. He has the support of his family in the U.S., and they want him to do well especially once he enters Kindergarten next year. Therefore, his mom is seeking services to help him.
Problem Statement: Ben and his mother face social isolation due to limited friends/family in the area to help them. Ben is lacking in social and fine motor skills which are impacting his play occupations.
Case-Smith, J. & O'Brien, J.C. (2015). Occupational Therapy for Children and Adolescents. (7th edition). St. Louis, MO: Elsevier Mosby.
Dickinson, K. (2017). Occupational Therapy's Perspective in Pediatric Feeding Disorders. Wichita State University.
Hye Ran Yang. (2017). How to Approach Feeding Difficulties in Young Children. Korean Journal of Pediatrics, Vol 60, Iss 12, Pp 379-384 (2017), (12), 379. https://doi.org/10.3345/kjp.2017.60.12.379
Intervention Approach: Modify
Adapt utensils to increase self-feeding that may be impacted from fine motor deficits.
Newborg, J. (2005). Battelle developmental inventory. (2nd edition) Itasca, Ill.: Riverside Pub.
Pados, B.F., Thoyre, F.M., & Park, J. (2018). Age-based norm-reference values for the Child Oral and Motor Proficiency Scale. Acta Paediatrica, (8), 1427. https://doi.org/10.1111/apa.14299
Intervention Approach: Create/Promote
Promote social skills with peers.
During play look for turn-taking, signs of aggression, or accepting of help.
Intervention Approach: Prevent
Ben's OT will educate his mother on his condition. This includes educating her on what his condition entails and will allow her to understand it and help her son more. She will also be educated on community resources for her (support groups, adaptive technology banks).
Fine Motor Skills
Problem Statement: Ben has had multiple surgeries to correct esophageal atresia, a condition which resulted in having a feeding tube placed in his abdomen for a long period. Recently, he is cleared to eat by mouth, however; he refuses to eat and gags at the presence of food.
Feeding/Eating
Within 6 weeks Ben will eat daily meals without food refusal evidenced by gagging, for 3 out of 5 opportunities with moderate assistance from his mother, as documented in his daily food journal, in preparation for daily eating routines.
Within 6 weeks, Ben will independently initiate eating in a group setting of his peers in preparation for kindergarten lunch room readiness.
Within 6 weeks, Ben will make a list of 5 foods he enjoys, with moderate assistance from his mother, in preparation for daily eating.
Within 6 weeks, Ben will independently pick up small objects using a pincer grasp 4/5 opportunities for preparation of play and grasping utensils during mealtimes.
Within 6 weeks, Ben will string and unstring small beads onto a string with moderate assistance from therapist for increased precision handling
Social/Play Skills
Within 6 weeks, Ben will independently role play a social scenario of his choosing, involving his peers with minimum verbal cues from therapist in preparation for Kindergarten readiness.
Within 6 weeks, Ben will independently initiate and participate in sensory play, such as sensory bins, for 5 minutes, with minimum verbal cues from therapist or mother.
Health and wellness: Ben will achieve adequate daily nutrition through a well-balanced diet via oral intake, decreased food refusal, and expansion of current food preferences. Ben will explore foods by observing his mom in preparing new foods/recipes. Ben may also assist his mother in gathering supplies and age-appropriate food preparation tasks These tasks may also improve Ben's fine motor skills.
Participation: Ben will initiate engagement and participation in social play among peers in preparation for Kindergarten. Ben will initiate social interactions with peers in both the playground and cafeteria/restaurant setting. Ben will develop enhanced play skills through increased social engagement.
Fine Motor Skills
Occupational Performance: Enhancement- Ben will utilize a inferior pincer grasp when eating finger foods and picking up small objects. Ben will use a tripod grasp for eating and writing utensils.
Willard, H. S., & Schell, B. A. (2014). Willard & Spackmans occupational therapy. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.
Creek, J. (2014). Approaches to practice. Creek's Occupational Therapy and Mental Health E-Book, 50-69. Elsevier Health Sciences.
