Jason
Medical Hx
Therapy Goals
LTG: In 9 weeks, Jason will finger feed while sitting in a supported position in a high chair with <3 verbal cues from caregiver, for 3/5 opportunities for 3 consecutive therapy sessions.
STG: In 5 weeks, Jason will ingest 2 new textures, without self induced gagging, during feeding with mod A from caregiver, while sitting supported in his highchair, for 3 consecutive mealtimes.
Assessment
Client Factors
Occupation-based problem list
Born at 26 weeks (premature)
Spent 6 months in NICU
TX: prune belly syndrome c urological abnormalities and abdominal wall atrophy, chronic kidney disease, chronic lung disease
D/C home on O2 and NG tube for nutrition
8 mo: readmitted to hospital due to O2 needed - required intubation and 2.5 week hospital stay - refused oral feeding and pacifier
Occupational Performance
Batelle Developmental Inventory 2
Toddler Sensory Profile 2
Parent questionnaire used to assess Jason's sensory processing patterns to determine effects on occupational performance to create individualized intervention plan
Observations conducted by OT along with parent interview are used to assess Jason's motor skills to determine developmental delays in functioning
Clinical findings: Jason shows delays in developmental milestones. Raking and palmer grasp are present, but are signs of fine motor delays for his age. Jason presents with hypotonia, poor postural control, developmental delays in crawling and walking, poor strength, low initiation of new tasks, age appropriate play with favorite toys, but does not explore other toys or items within the environment; he is able to drink from a sippy cup but does not self feed
Clinical findings:Based on Jason's scores on the SP2, he is sensory avoiding and experiences sensory sensitivity. Jason does not like new textures of food or toys, he does not walk or crawl, he finds loud environments stressful and often lashes out as a result, he does not explore new food and will cry when his hands are messy, he shows no interest in self care tasks such as dressing, bathing, grooming, and self feeding.
Client Profile
2.5 year old male
lives at home with mom, dad, and two older sisters
Enjoys music, watching movies, playing with stuffed animals and superhero toys
Feeding
Mobility
Child does not participate in self-feeding
Mother concerned with this delay
Jason does not have postural control or strength to sit unsupported during ADLs; he does not walk or crawl
Eating
Jason rejects nonpreferred textures
Jason only eats soft food textures and thick puree
Jason cries when given to noxious textures
Jason does not have postural control or strength to sit unsupported so that hands are free to feed
Intervention Strategies
Eating
Strength and mobility
Self feeding
Family goals and priorities
Posture: poor
Reflexes
References
Medscape. (2017). Prune belly syndrome. Retrieved from https://emedicine.medscape.com/article/447619-overview#a11
American Occupational Therapy Association. (2014). Occupational
therapy practice framework: Domain and process (3rd ed.).
American Journal of Occupational Therapy, 68(Suppl. 1), S1–
S48. http://dx.doi.org/10.5014/ajot.2014.682006
Intervention activity: Place Jason in lap with a neutral pelvis, facing away. Gently bounce him with lap to stimulate contraction of muscles activated for postural stability that is required for feeding, grooming, and dressing tasks
Increase participation in IND feeding
Promote sensory modulation
PEOP Model (Cole & Tuffano, 2008)
Top-Down approach
Cole, M.B. & Tufano, R. (2008). The person environment occupation participation model. Applied Theories in Occupational Therapy: A Practical Approach (pp. 127-133) Thorofare, NJ: SLACK.
Interventions aimed at enhancing occupational performance
Development of life skills
Focus on person, environment, occupation, and performance transaction
Environmental adaptations
Create occupational profile to identify strength and weaknesses
Identify environmental barriers and supports
Client-centered
Enhance role performance and satisfaction
Focus on client participation meaningful activities
Mealtime: Being able to eat as a family, without Jason experiencing distress during eating (refusal and rejection)
Increase oral food intake, acceptance of more food textures
Independent feeding
His parents show frustration with his developmental delays and state they don't understand how to care for his needs
They want him to be more like other kids his age
Jason shows developmental delays in fine motor skills, gross motor skills, dressing skills, feeding skills, grooming skills, and static sitting balance. Jason would benefit from skilled OT services to address these developmental delays to promote IND in ADLs
Jason would benefit from skilled OT services to address sensory systems and promote sensory modulation during eating, play, and grooming.
Intervention activity: Offer Jason food at meal-appropriate times. Sit Jason in the highchair with small, cut up portions on his plate to promote finger feeding. Demonstrate finger feeding and have Jason mirror it.
Intervention activity: Allow Jason to play in food to explore different textures then bring food up to mouth. Provide smooth textures and crunchy textures mixed within.
Intervention activity: Introduce new textures gradually to preferred foods
Intervention activity: Reduce hyperreation of contact between teeth with food and toys by using a vibrating toothbrush to stimulate mouth; begin with toothbrush at chin and cheeks, until Jason parts his lips to allow the toothbrush in to his mouth
Intervention activity: Practice supported static sitting balance with trunk supports to promote good postural alignment needed for success in ADLs while child moves arms freely to manipulate toys at a table. Provide caregiver education and have them practice this 3x daily
Grade down: Use old batteries that will provide a low frequency of vibration
Grade up:
Incorporate 15 second intervals of unsupported static sitting balance while child manipulates and reaches for toys
Grade down: Practice supported sitting balance c truncal and head support; child will not participate in play
Performance Skills:
hypotonia
frog position in supine
Strength: poor
Weakened abdominal muscles due to prune belly syndrome
Gross motor: Jason scoots in supine and rolls, unable to quadruped for crawling
Fine motor: Palmer and raking grasp present
Fine motor grasps to promote self feeding and confidence
Intervention actviity: Incorporate spoons and forks into play to work on palmer grasp by having Jason stab cheese blocks with fork while sitting supported at table
Intervention activity: Have Jason sitting supported at a table and work on pincer grasp by having him play with play dough. Encourage him to squeeze into the play dough with this thumb and index finger to promote fine motor skill development and increase hand strength.
Grade down: Have Jason free play with spoon and fork to get comfortable with grasp
Grade up: Place utensils further away to promote reach and grasp
Recognize environment and person relationship as dynamic and reciprocal
Grade up: Use more powerful batteries to enhance stimulation
Parent education: Provide education on Jason's nonverbal cues so they understand when a tantrum is about to happen and to remove the stimulus; provide empathy during stressful times rather than expressing frustration; do not push Jason to eat new items so there is no power struggle
Self-induced vomiting with 'noxious' textures
lack of protective reflexes
Play: Jason will manipulate preferred toys, but shows anxiety when presented with new toys of varying textures
Unable to lift objects above chest
unable to maintain unsupported sitting balance
Communication: Jason mainly communicates through crying and babbling. He is capable of one to two word sentences, but relies on nonverbal communication. When he is hungry or dirty, Jason will cry out to his parents for help. When he wants a favorite toy, Jason will point and babble
Dressing: Assists parent in UB dressing, no interest in LB dressing
Toileting: Jason experiences frequent constipation due to abdominal wall weakness and frequent UTIs due to kidney disease . He is not potty trained.
Grooming: Client shows no interest in self care tasks, resists tooth brushing
Feeding: does not perform self-feeding with hands or utensils, but will hold and drink from sippy cup; only eats thick purree, bread, cheese slices, and soft foods; does not explore foods; does not eat crunchy, hard textures
Bathing: Jason does not like baths and will scream once placed in the tub ; he does not play in tub and relies on caregiver to bathe him
Current method of feeding:
Mother feeds child while lying supine on the couch, with body propped up on a Boppy pillow, Jason is unable to IND hold body or head upright. Jason will only eat certain food, and will reject any other textures through crying, screaming,and hitting. Mother uses G-tube during mealtimes where Jason refuses all food.
Decrease self-induced emotional vomiting and gagging
Intervention activity: Create a calming, supportive environment with decreased distractions and calm music to inhibit overload during eating. This will be a safe place for the child to retreat and calm down in times of stress. Take time to create positive association with foods and mouth
Intervention activity: Use appropriate mealtime-related distractions during introduction of new textures. When feeding Jason a noxious texture, begin singing a song or let the child play with a favorite toy to prevent overreactions and relieve anxiety. If Jason begins to gag, ignore him by using a gag distrction. Provide parent education on this technique.
Grade up: Incorporate more noxious textures within play with food, such as crunchy cereal or crackers
Grade down: Allow child to play in food, but caregiver provides mod A to assist child in bringing food to mouth
Sensory modulation issues, no structural basis for gagging and vomiting as determined by MBSS
Begin with familiar foods and introduce new textures within these foods. Examples: placing cereal into pudding, making lumpy mashed potatoes, placing mashed strawberries into oatmeal
Surgeries
2.2 yo: G-tube placement for nutrition due to refusal to eat
2 yo: cervical spine stenosis correction
20 mo: uretostomy reversal, adbonimoplasty, orchipety
7 mo: curcumsicion
6 mo: double urectostomy
prior to birth: 5 fetal sx to address kidney blockage
Social Participation: Family
Jason is unable to adequately participate in his role as a son and brother due to his sensory avoidance
Social participation: Family
Role competence
To encourage Jason to begin IND dressing, have him put clothes on his favorite super hero toys (The OT Toolbox, 2016). Use a song that the caregiver and Jason will sing during this play, then incorporate it into dressing. This will increase self confidence and build fine motor skills needed for dressing and grooming.
Specific feeding skill issues. [Class notes]. Retrieved from https://class.usa.edu/webapps/blackboard/content/listContent.jsp?course_id=_115595_1&content_id=_3617585_1
Sensory Issues. [Class notes]. Retrieved from https://class.usa.edu/webapps/blackboard/content/listContent.jsp?course_id=_115595_1&content_id=_3617585_1
Physical issues. [Class notes]. Retrieved from https://class.usa.edu/webapps/blackboard/content/listContent.jsp?course_id=_115595_1&content_id=_3617585_1
Cargiver education: Provide strategies and education to all family members about Jason's sensory reactions. Help them with techniques to build trust with Jason during ADLs, understand his verbal cues, and incorporate play and social communication within their daily routines with him
Grade up: After Jason places the article on the toy, he will point out his same article of clothing and assist the caregiver with dressing himself
Grade down: Jason will assist the caregiver in dressing his toy
He will scream and cry at restaurants which limits community outing for his family
Jason does not interact with sisters while in play; if they take away his favorite toy or give him a new one to share, he will begin to scream and cry
He experiences melt downs at home limiting his family interactions during play and mealtime
Jason is dependent on his caregiver to feed, bathe, and transport him, as well as change his diaper
Supports
Barriers
Jason has a strong family support system; his parents are active participants in therapy and will work on his developmental skills at home; Jason does assist in UB dressing and IND drinking from a sippy cup; he has some fine motor and manipulation skills
Jason shows no interest in self care activities or feeding; he is experiencing hyperreaction to sensory input; he relies on a G tube for nutrients; he is showing signs of developmental delay; he experiences chronic UTIs due to kidney disease, which affect mood
The OT Toolbox. (2016). Independence with self dressing and fine motor skills. Retrieved from http://www.theottoolbox.com/2016/04/independence-self-dressing-fine-motor-skills.html
Grade up: Bring family members into the room to eat with Jason
Grade down: Focus on getting Jason comfortable within the room, do not provide feeding