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Emily (Client factors (strengths: (likes schedules, Good strength in B LE,…
Emily
Client factors
7 y.o female w/ autism spectrum disorder
2nd grader
strengths:
likes schedules
Good strength in B LE, and UE
Has many friends
enjoys dancing
likes technology such as her iPad
Occupational performance deficits
Difficulty with following 5 step direction
Delayed cognitive functioning
Has a younger brother, 5 years old
Has a yellow lab, 5 year old, Moose
Medical History
Diagnosed with autism at 5 years old
Dyslexia
she broke her R wrist at recess 2 years ago -completely healed
medication for sleep
DOB: 6/ 14/2012
Habits/routines/rituals
Habits:
Always needs to have a snack before bed
Always likes to fall asleep after watching something on the iPad
Routines:
Every Friday afternoon is ballet practice
Sundays: church with grandparents
Rituals
Family prays before they eat
Helps mom cook dinner every night
Context/environment
Physical
Church on Sundays with grandparents, one story church building
Lives in two story home
School
dance class
Social
dance class with other friends
school playing with friends at recess etc
plays with her brother at home
plays with her dog
social interactions with grandparents/parents
Virtual
uses iPad frequently
TV
Problem List
Emily has limited verbal expression
Emily has difficulty falling asleep at night
Has difficulty sitting still
Occupations/roles
Roles:
daughter
sister
ballerina
student
Granddaughter
Occupations:
eating
Eating independently
points to picture choice to let parents and teachers know what she wants to eat
toileting
toileting independently
dressing
Dresses with modified independence, requires some verbal cueing
Grooming/brushing teeth
Brushes teeth w/modified independence, requires verbal cueing
dancing
difficulty following 5 steps in dancing
follows 3-4 steps
playing
Goals:
LTG:
In 3 months, Emily will complete bedtime routine, with use of visual schedule , with modified independence, 5 out of 7 days, for 3 consecutive weeks, per parent report , for increased indepenfence with sleep preparation and sleeping.
STG:
In 6 weeks, Emily will complete bedtime routine, with visual schedule , with modified independence, 2 out of 7 days, for 2 consecutive weeks, per parent report , for increased independence in sleep preparation and sleep.
Hillary Matthews, Kathryn Ewert, Brianna Beason