Jake (Interventions (Motor plan creation (Addresses Jake's lack of…
Sensory food tolerance
Sensory integration/ processing to address his sensory discrimination, motor planning, and self-regulation; this offers Jake sensory experiences that include proprioceptive, tactile, and vestibular inputs in the contexts of play.
Sensory Processing/ integration to address Jake's texture refusal and gagging reaction by grading foods due to reduced avoidance tendencies; allow independence and freedom of choice for Jake to try things on his own. Begin with a pureed diet and eventually work up to a normal diet; allow Jake to choose his preferred food and visualize the pureeing process (Nederkoorn, Theiben, Tummers & Roefs, 2018).
Motor plan creation
Addresses Jake's lack of exposure in the creation & practice of mealtime-specific motor plans; scooping sand / other materials (fishing out specific items from sand) with feeding utensils to create new motor programs that are feeding specific and simulate feeding sequences (Hodge & Gaines, 2017).
Incorporates smooth motor plan performance can translate to mealtime by showing less spillage of food from spoon/fork (the more he practices using the tools, the less spillage) (Muldoon & Cosbey, 2018).
Utilize bimanual hand coordination of stabilizing with one hand and utilizing a utensil in the other.
Time organization and scheduling
Educates Jake and teaches him about varied utensil and tool use, along with tastes, smells, textures, and colors of different foods to allow him to decide what he likes and does not like (place spoon/ fork/bowl/plate and food item in symbol form on schedule)
Address the lack of consistency during meal time and food administration exposure by using a feeding schedule to include more frequent, smaller meals; can incorporate visual schedule with food options to allow Jake to choose his meal.
Allow Jake to take part in mealtime routine of set up and clean up to facilitate further knowledge on the use of tools, facilitate fine motor control (i.e. holding/cleaning utensils; work on direction following in these tasks). This can help prepare him for the routine demands in Kindergarten (Heffron, 2016).
Address the lack of social participation opportunity by introducing him to a Spanish speaking support group (of like ages) to provide opportunities for social participation and social development (George, Norman, Benjamin & Mukherjee, 2014).
This includes play groups, games, group story time (which also addresses language development and turn-taking for speaking). This can also be done in a group OT session (Heath, Wigley, Hogben, Fletcher, Collins, Boyle & Eustice, 2018).
Provide the mother with an extensive list of alternative food options that are more suitable to Jake’s preference.
Educate mother on the importance of self-feeding to learn the feeding motion, sequences of meal time, social participation during meal time, enhancement of fine motor skills during meal time, and improve motivation for food exploration.
Educate mother on the importance of the time schedule for mealtime to incorporate consistency and routine. Educate her on the concerns of aspiration and respiration issues that could lead to choking, gaging, or vomiting.
Aspiration and respiratory concerns
Be cautious of potential respiration and aspiration during mealtime secondary to esophageal atresia.
Educate Jake and mother on eating more frequent and smaller meals. Give verbal cues to always chew thoroughly before swallowing, clearing the mouth before taking another bite, and taking deep breaths during mealtime (Shmaya, Eilat-Adar, Leitner, Reif & Gabis, 2017).
Models and FOR
(Cole & Tufano, 2008)
Person Environment Occupational Performance (PEOP) Model:
Jake’s ability to successfully engage in self-feeding / eating is dependent on the environmental factors / barriers of culturally-based food choices and feeding implementation from Mom
Model of Human Occupations (MOHO)
Jake is highly motivated to eat / play but is just is afraid to try textures / tasks out due to negative past experiences (Mom is inconsistent with time of day & method of food exposure, food he HAS been exposed to has been on the spicier end, and he had little to no independence in the exchange as she tried to feed him and wouldn’t let him explore on his own)
Sensory Processing FOR
Jake is experiencing sensory processing issues which are impeding his abilities to eat/swallow his food without gagging.
Motor Control and Learning FOR:
Jake has little to no experience building / creating mealtime-specific motor plans (no past practice of tool use due to never using tools for tube feeding)
Lifespan Development FOR
Jake is delayed in his development of social participation skills and self-feeding skills / ability
Jake has inadequately developed fine motor skills & dexterity required in many meal specific tasks as well as that are expected in Kindergarten aged students.
Occupations (AOTA, 2014)
Swallowing / eating (due to issues swallowing food).
Feeding (hand eye coordination / feeding sequence steps)
Education: formal education participation
Play: play exploration and play participation
Social participation: peer, friend, and community; due to lack of exposure and cultural barrier.
Client Factors (AOTA, 2014)
Values: Feeding has been and initiated and executed by mom.
Mental & Sensory functions: sequencing of complex movement, and taste, smell, and touch functions.
Body Structures: structures related to digestive, metabolic, and endocrine system. Possible respiratory and aspiration concerns.
Performance skills (AOTA, 2014)
Chooses / uses- does not understand the differences between the correct tools to use
Handles- difficulty with supporting and stabilizing tools
Initiates- moves entire bowl when scooping with other hand
Sequence- difficulty following correct steps and order to perform eating task
Navigates- faces issues with smooth movements of UE and bilateral coordination
Social Interaction Skills
Approaches / starts- difficulty initiating interaction with other peers
Looks- avoids eye-contact when interacting with others
Takes turns: unaware of taking turns to speak during a conversation
Expresses emotions- displays inappropriate behavior when working with other children, and does not know how to express upset/angry behaviors.
Manipulation - issues with finger dexterity to manipulate and securely hold food (FMC)
Coordination - issues with using TWO body parts to manipulate, hold, stabilize task (hold bowl with one hand and scoop with spoon in another)
Performance Patterns (AOTA, 2014)
Routines: Fed by his caregiver for all three meals (lack of opportunity of self-feeding / independence in meal time). Lack of mealtime routine due to past methods of eating (anything tried in past has been inconsistent and varied with time and method administration).
Role: Child and son. Peer / student with the inability to follow turn taking and poor collaborative play & effective communication ability
Contexts and Environment (AOTA, 2014)
Physical: lives in small apartment with 3 other adults; limited to exposure to other children and lacks age appropriate toys (though makes due as much as possible).
Social: Isolated due to community barriers and lack of formal education opportunities. Also has communication barrier. Mom and son are limited to outside supports aside from her cousin and his wife (lack friends)
Temporal: has difficulty taking turns and playing with other children his age and lacks self-soothing behaviors that a typically-developing 5-year old should have.
Personal: a child who has undergone 3 surgeries to address esophageal atresia (delayed child-specific growth towards milestones)
Cultural: in crucial fine motor development periods (during meal time), the mother takes control of feeding and several manipulation tasks due to Hispanic heritage and norms associated with mealtime. Jake is also exposed to purely Mexican food, which is a taste that he may not enjoy (ex: too spicy).
Virtual: enjoys watching Dora the Explorer on TV (Boots is his favorite)
Occupations and Activities:
ADL specific: simulate meal times to break down and work on weak areas.
Play activities: introduce turn taking, emotional regulation, and expressive language.
Preparatory Methods and Tasks:
Fine motor skills with fine motor kit.
Education and Training:
Allow him to choose food to include him in meal preparation via food exploration.
Educate mom on how to implements visual feeding schedule with proper utensil handling.
Educate mother on the possible aspiration and respiratory concerns that could lead to choking, vomiting, or gagging.
Advocacy (caregiver based):
Collaborate with mom and school OT on how to implement feeding schedule, on proper utensil handling, and utilizing smaller bites.
Explore the opportunities to have a translator for Jake and his mother
Introduce mother to Spanish speaking community group to help enhance social participation and outside supports.
Facilitate play between Jake and other Spanish speaking peers.
Outcomes and LTGs
Readiness for Kindergarten
LTG: In 6 weeks, Jake will be enrolled in kindergarten ESL program, with school-based OT present 1 out of 5 days per week, for a 1 hour session, to facilitate smooth transition into school setting.
Improved social participation
LTG: In 6 weeks, Jake will attend, with mother present, a Spanish speaking group of peers 2 times a week to address deficits in social participation.
LTG: In 6 weeks, Jake will participate in teacher led group activity, following classroom-specific rules and directions with 3 or less verbal cues, per teacher report, to address social participation in routine-based play.
Improved fine-motor skills
LTG: In 6 weeks, Jake will independently self-feed with an appropriate tool, spilling less than 25% of meal, 3 out of 5 meals per day, per parent report, to address fine motor skills required in mealtime.
Improve parent community engagement
LTG: In 6 weeks, Mom will schedule 1 playdate per week between Jake and another Spanish speaking child, in 3 out of 6 weeks, per parent report, to enhance Jakes social participation skills and facilitate age-appropriate play.
Improved swallowing ability / tolerance of different textures
LTG: In 6 weeks, Jake will independently swallow at least 2 solid items of food during 2/3 meals without gagging, per parent report, to address eating during mealtime.
School Function Assessment (SFA)
This will be used to asses formal social participation and his readiness to start kindergarden. Analyzes task supports and activity performance in school tasks
Peabody Developmental Motor Scale 2 (PDMS-2)
Performance based assessment that explores his fine and gross motor abilities and compares it to the norms of other children his age
Battelle Developmental Inventory 2 (BDI-2)
Addresses personal social, adaptive, motor, communication, and cognitive domains
Videofluoroscopic Swallow Study (VFSS)
Dianosis for oropharyngeal aspiration
Esophageal atresia (EA)
Symptoms: first signs is EA include frothy white bubbles inside and around the mouth area, respiration issues, and complications during feeding, such as coughing, choking, or discolored blue skin (Boston Children's Hospital, 2018).
Prognosis: treatment approaches involve early surgery to connect the two ends of the esophagus together (Boston Children's Hospital, 2018). These approaches involve the Foker process, static internal traction, dynamic, internal traction, jejunal interposition, and/or primary anastomosis (Boston Children's Hospital, 2018)
Prevalence: average prevalence of 2.44 per 10,000 births, with prevalence rates varying depending on the geographical region (Cochran, 2018).
Diagnosis/disability: EA is a concern when infants at birth express early signs of choking, coughing, and turning blue during feeding (Boston Children's Hospital, 2018). It is also diagnosed by the failed attempt of passing a feeding tube into the infant's stomach through the nose/mouth, and confirmed with an x-ray (Boston Children's Hospital, 2018).
Incidence: 1 in 3,500 live births, with 50% experiencing other congenital malformations (Cochran, 2018).
Condition: birth defect where the formation of a continuous esophageal tube is interrupted, resulting in a disconnected upper esophageal tube from the lower esophageal tube (Boston Children's Hospital, 2018).
Social participation and play for typically developing 5yo (CDC, 2018)
Able to speak clearly and use full sentences
Able to follow and agree with rules
Desire to please and be liked by friends
Fine motor abilities for typically developing 5yo (CDC, 2018)
Able to use a fork, spoon, and table knife independently
Can swing and climb using hands
By: Nikki Gordon, Evan Larsson, Linda Mai