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Flynn 4-years-old (History (Born at 38 weeks gestation, Cesarean section,…
Flynn 4-years-old
History
Born at 38 weeks gestation
Cesarean section
birth weight: 6 lbs 3 ounces
obstructive sleep apnea
diagnosed
with micrognathia
clubfoot
Genetic testing positive for Congenital Myotonic Dystrophy
Vision and hearing tests are reportedly normal
References
Kramer, P. & Hinojosa, J. (Eds.). (2010).
Frames of reference for pediatric occupational therapy
(3rd ed.). Baltimore: Lippincott, Williams & Wilkins. ISBN: 13:978-0-7817-6826-9.
Boop, C., Smith, J., & Kannenberg, K. (2017). The practice of occupational therapy in feeding, eating, and swallowing.
American Journal of Occupational Therapy
, 71, 1–13. Retrieved from
http://prx-usa.lirn.net/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=127183748&site=eds-live
Tsu-Hsin, H. & Tien-Ni, W. (2013). Systematic review of interventions used in or relevant to occupational therapy for children With feeding difficulties ages birth-5 years.
American Journal of Occupational Therapy
, 67(4), 405–412.
https://doi-org.prx-usa.lirn.net/10.5014/ajot.2013.004564
Chicago/Turabian
Marcus, S., Breton, S., & Brookes, N. (2012).
Pediatric Feeding and Swallowing: A Practical Guide for OTs.
American Occupational Therapy Association (in press).
Hurley, K. M., Cross, M. B., and Hughes, S. O. (2011). A systematic review of responsive feeding and child obesity in high-income countries.
J. Nutr.
141, 495–501. doi: 10.3945/jn.110.130047
Newborg, J. (2005). Battelle Developmental Inventory, 2nd Edition. Itasca, IL: Riverside.
Method of feeding
Flynn will eat puréed foods from pouches held by an adult or offered on a spoon
He is able to use an open cup but prefers a straw-cup or a 360 cup
Prefers to finger feed
resistant to utensil use
Grading Interventions
Swallowing (pacing)
Grade (+)
Remove ounces of Gelmix from Flynn's meals to make the consistency of the meal thinner, requiring Flynn to maintain control over his swallowing (Marcus, Breton, & Brooks, 2012).
Grade (-)
Place additional ounces of Gelmix to Flynn's meals for a thicker consistency to allow for pacing during swallowing. Flynn suffers from constipation, however, Gelmix is a nectar that does hinder bowel movements (Marcus, Breton, & Brooks, 2012).
Eating (positioning)
Grade (+)
Remove positioning belt and other stabilizers for neutralizing body position during eating, allowing for Flynn to exercise more control over his posture.
Grade (-)
Apply positioning belt at 45 degree angle to maintain a neutral pelvis, while supporting Flynn's neck and trunk to provide assistance during eating (Hurley et al., 2011).
Feeding (in-hand manipulation)
Grade (+)
Use a typical pencil to trace in multiple shapes and directions. This activity will require fine motor and in-hand manipulation skills to be more accurate.
Grade (-)
Use a wider pencil with a grip to draw large simple shapes. This grip requires less fine control during grasping, and large simple shapes will require less effort for manipulating the pencil.
Feeding (bimanual coordination)
Grade (+)
Practice bimanual coordination by using both hands to catch and throw a tennis ball. Catching a smaller ball will require an increased amount of bimanual and visual-motor skill accuracy
Grade (-)
Practice bimanual coordination by using both hands to throw and catch 10 inch ball. Catching a larger ball with both hands will require less visual-motor and bimanual accuracy.
Occupation-based Problem List
Feeding
Refusal to eat with utensil without the assistance from caregiver impacting the occupation of self-feeding
Impaired in-hand manipulation and bimanual skills affecting drinking from open cup without excessive spilling
Eating
Food manipulation impaired due to decreased muscle tone and Mycrognathia impacting the occupation of eating
Swallowing
Impaired swallowing due to dysphasia, causing movements of food/liquid from mouth to stomach to be difficult
Interventions
Eating
Apply the use of a positioning belt at a 45 degree angle to maintain a neutral pelvis during eating (Hurley et al., 2011).
Use flexed neck and reclined trunk positioning to minimize or eliminate aspiration to promote successful performance during eating (Tsu-Hsin & Tien-Ni, 2013)
Feeding
Practice extinction strategies to facilitate utensil use during feeding by placing the utensil in Flynn's mouth and allowing him to remove it on his own (Tsu-Hsin & Tien-Ni, 2013).
Utilize the application of positive reinforcement with verbal praise or brief access to a preferred toy or activity immediately after achieving self-feeding with utensil (Tsu-Hsin & Tien-Ni, 2013).
Practice throwing and catching balls to improve bimanual upper extremity coordination
Flynn will practice drawing activities with a pencil to increase his in-hand manipulation skill necessary for holding utensils.
Swallowing
Place Flynn in upright or left side-lying positions to facilitate efficient swallowing (Marcus, Breton, & Brooks, 2012).
Add the thickening substance of Gelmix to Flynn's meals to facilitate pacing during swallowing (Marcus, Breton, & Brooks, 2012).
Assessments and Results
Occupational Profile
Supports to occupational engament
Flynn has a chair with supports his caregiver uses during feeding, and he does not show any sensory aversion to his physical surroundings
Flynn's has social support from mother, father, grandparents. and older sister.
Flynn sustains attention on virtual entertainment sources such as television and music
Barriers to occupational engagement
Flynn's supported feeding chair provides some stabilization during feeding, however, Flynn still exhibits poor posture
Flynn refuses to use utensils during meal time unless his mother is present to spoon feed him
Flynn's mother reports a desire for Flynn to use utensils during mealtime because it is appropriate for their family
Flynn resists communication methods via iPad applications
Occupations in which the client is successful
Flynn's grasps are developmentally appropriate
Actively participates in toilet training
Flynn sleeps through the night with appropriate sleep apnea management
Flynn actively participates in exploratory play and parallel play
Clinical Observation
Flynn exhibits a posterior pelvic tilt while sitting in his feeding chair
Flynn has associated mealtimes with distress and sometimes creates unwarranted behaviors such as utensil refusal
Hypotonia present throughout, creating weakness in upper extremities. Weakness influencing bimanual coordination during feeding.
BDI-2 Adaptive Self Care
Flynn was assessed using the adaptive self-care subdomain of the BDI-2 in the age range of 48-59 months. Self-care is a 35 question subdomain addressing areas of a child's ability to perform daily routines, specifically the section of eating will be discussed for Flynn. Scores are indicated with a 2, 1, and 0. 2 indicates typically or 90% of the time, 1 indicates sometimes, and 0 indicates rarely. (Newborg, 2005)
Assessment Results
2 (typically)
Flynn did not score a 2 on any section of self care regarding mealtime
1 (sometimes)
Choosing the appropriate utensil for the food he or she is eating
0 (rarely)
Asking for food verbally at the table
Obtains a drink from a tap or other sources without assistance
Child cuts soft foods with side of a fork
Goals
STG
In 6 weeks, Flynn will drink from an open cup, independently with minimal verbal cues, and minimal spilling, three times daily, for 1 week consecutively, as reported by parents, for increased independence in drinking.
LTG
In 12 weeks, Flynn will feed himself, using a utensil, independently, twice daily, for two weeks consecutively, as reported by parents, for increased independence in feeding.
Current Functional Performance
client factors
Resistant to UE WB in quadruped
Poor active movement above shoulder level
Flynn can sit unsupported on the floor but is unable to sit on an elevated surface without close
supervision/CGA
Flynn can raise self into standing using upper extremities and lifting self from one surface to
another.
Not yet crawling and inconsistently walks with either hand held assist or use of a Kaye
walker; though he can scoot across the floor and up/down steps.
Hypotonia throughout
No sensory processing concerns
Flynn maintains attention to tasks well
performance skills
Developmentally appropriate grasps; though impaired in-hand manipulation and bimanual skills
Impaired VM skills related to pre-writing shapes and cutting
Flynn is non-verbal, pointing and vocalizing in an attempt to communicate; attempts to introduce
communication device results in resistance due to inability to access tablet apps.
Caregiver priority
Participation in feeding with the use of utensils
Drink primarily from an open cup
Biomechanical FOR for Positioning Children for Functioning
This FOR is appropriate for Flynn because it is applied to individuals that cannot maintain posture through appropriate muscle activity due to neuromuscular or musculoskeletal dysfunction (Kramer & Hinojosa, 2010).
Flynn demonstrates poor oral motor control resulting from decreased muscle tone. The absence of adequate head and trunk control exacerbates oral motor functions, creating a need for positioning strategies. This FOR states positioning is designed to reduce the influence of low muscle tone on oral motor activities (Kramer & Hinojosa, 2010).
Flynn's impaired hand manipulation and bimanual skills can be addressed through modification of muscle tone in the trunk and shoulders, which may improve tone in the extremities. Control of hand placement provides more opportunity for manipulation and the sensory experiences necessary for fine motor control (Kramer & Hinojosa, 2010).
