Evaluation:
Cindy's occupational performance has been evaluated over time by looking at her strengths and weaknesses in areas of occupation, performance skills, performance patterns, context, activity demands, and client factors. An assessment of the families values, needs, and priorites were also taken into account. This information was gathered using standardized tests scores, parent interview, and professional observation. Results were as follows:
Occupational Performance:
1.
Performance Skills:
a.
ADL's and IADL's: On the Batelle, Cindy was found to be demonstrating a 64% delay in adaptive development. She currently finger feeds herself, uses a spoon infrequently, removes clothing, and drinks from a sipper cup. Oral and tactile sensitivities hinder development in feeding, dressing, and grooming.
b.
Social Participation: Cindy was found to have an 82% delay in social-personal development according to the Batelle. She is an only child in a single parent household. She does not have many social demands placed on her. When she attended a private daycare for a short time, she did not interact with the other children. She actively and passively avoided social situations by withdrawing or by physically removing herself. She occasionally ran into potentially dangerous situations like running toward the road. Cindy does not eat at the table with her mother but "grazes" througout the day. She tends to become overstimulated when out in the community (grocery store, restaurants, doctor's office), demonstrating an increase in challenging behaviors. Cindy has begun to demonstrate improved interactions with her mom however. Cindy's mom recently reported that Cindy will sit at the top of slide and say "ready, set... " and wait for her mother's response to say, "go" before she slides down. Cindy has also recently demonstrated an increase in joint attention, looking for her mother's reaction while involved in an activity of enjoyment. Overall, poor eye contact, difficulty with novelty, delayed speech, and a rigid need for familiar routine continue to hinder Cindy's social success.
c.
Play and Leisure: Cindy is beginning to demonstrate interest in what her mother or therapists are doing. Initially, she ignored others and demonstrated narrow interests with a preference for coloring, watching television, or staring at her video boxes. She was highly resistive to unfamiliar tactile and vestibular forms of play. She is now more accepting of movement and "messy" forms of play. Cindy has also begun to show the emergence of imaginative play, feeding her stuffed animals and making her butterfly toy fly through the air. These skills have been learned and an expansion of spontaneous skills has not yet been observed.
d.
Educational, Vocational, and Pre-Vocational: Cindy demonstrates a 29% delay in cognitive skills according to the Batelle. She is beginning to learn the expectations of a structured environment by sitting and attending during home-based speech, special instruction, and occupational therapy sessions. She needs to work on completing morning routines efficiently so, when she transitions to a center based program, she will arrive on time and in a fairly calm state. She rides well in a car with her mother. It is anticipated that riding a bus will be anxiety provoking for Cindy. Cindy's cognitive and perceptual skills for success in the classroom will likely be influenced by Theory of Mind challenges (doesn't appear to understand others emotions, demonstrates decreased joint attention and minimal desire to elicit pleasurable responses from others), difficulties with executive function like planning, sequencing, cognitive flexibility, working memory, and monitoring and stopping inappropriate behaviors (Miller-Kuhaneck, 2004), and weak Central Coherence and local to global processing (detail oriented with difficulty in "seeing the whole picture").
2.
Performance Patterns:a. Motor Skills: Srengths
: Cindy is able to navigate her home environment independently, climb into adult furniture, climb stairs, and go up and down a slide. Concerns: Cindy demonstrates decreased muscle tone and joint instability, weakness, decreased endurance, a slouching posture, instability, immature and/or atyical grasp patterns, fine motor dyspraxia, no hand dominance, fair bilateral integration of upper extremities, and fair imitative skills.
b.
Process Skills: As mentioned above, difficulty generalizing information and applying it to broader, more global terms is challenging for Cindy. She did however, recently run to her room to obtain a toy telephone when we were playing with a puzzle that had a telephone on it. She has difficulty with executive functioning skills. She also demonstrates periods of high and low energy, affecting her ability to actively participate and attend to task. Energy levels are likely influenced by the foods she eats, poor sleeping patterns, and the complexity of the environment.
c.
Communication and Interactive Skills: Upon initiation of services, Cindy was jargoning without intent to communicate, repeating phrases from her videos, and tantruming to communicate. At her initial evaluation, she was demonstrating a 2.6 standard deviation belwo the mean in expressive communication. Cindy has recently demonstrated an explosion in labeling, although she has difficulty relating learned labels for functional communication. She demonstraes difficulty understanding questions, interpretting emotions, reading nonverbal gestures and the meaning of stress put on words like "hot" and "no". Overall, she is demonstrating gains in her ability to communicate and interact with her mom and therapists where routines and expectations have been established. She continues to have difficulty relating to unfamiliar people.
3.
Performance Patterns: Cindy's current role is to play at home and to periodically go into the community with mommy. She does not have strong demands placed on her in her current environment as her mother has typically provided her with what she desires and has avoided placing Cindy in situations where she demonstrates heightened signs of distress. Cindy will soon be transitioning to a center-based preschool program and will have many new demands placed on her (morning routine of washing, dressing, eating, and getting on the bus; interacting with unfamiliar adults and peers in an unfamiliar environment; being required to attend and participate in potentially anxiety producing situations). Although improved, Cindy has demonstrated habits that interefere in performance (wearing only diaper, staying awake very late into the night, and eating a limited variety of foods). Her desire for sameness in her routine was initially very difficult to break (refusal to separate from television, to color on anything other than 8 1/2 x 11" sheet of paper, grazing instead of eating at table) and met with negative behavioral responses.
4.
Client Factors:a.
Sleep: Cindy stays up late. Falls asleep where ever she is tired (on floor, on sofa). She does not sleep soundly, awaking several times throughout the night.
b.
Posture and Tone: Cindy demonstrates decreased muscle tone and joint laxity. She also demonstrates reduced endurance, strength, and a slouched posture.
c.
Arousal and Attention: Cindy's arousal is inconsistent and tends to go between both extremes, finding it hard to achieve a "just right" level of alertness. Her attention to task varies on the activity and her level of arousal.
d
Cognitive skills: Cindy demonstrates some problem solving skills such as moving a chair to obtain an object that was set out of reach. Overall, her reasoning appears impaired. Due to her age and performance, it is difficult to have a good understanding of her memory. She recognizes familiar people and familiar activities.
e.
Temperment, Personality, and Emotional Function: Cindy can be very cuddly and loving. Her activity level tends to be too high or too low. She reacts immediately and fully to perceived stressors, demonstrates varying attention to task depending upon the activity, and demonstrates initial apprehension or avoidance to novel activities.
f.
Sensory Functions: The Winnie Dunn Sensory Profile for Infants and Toddlers indicated probable differences more than others in: senation seeking; sensation avoiding; and oral processing. A definite difference more than others was found in: low registration; sensory sensitivity; low threshold; auditory; visual; and tactile processing. Overall, Cindy odemonstrates sensitivity to certain sounds, movement, tactile input, and oral input. On the other hand, she was underresponsive to voices and other sounds, craves deep pressure input "on her terms", and is seeking of oral input. She has difficulty regulating her states and sleeping patterns. She demonstrates immediate, intense responses to perceived stressors. He sensitivities have interferred in ADL development (dressing, groom, eating), play exploration, and social interactions.
5.
Context: Cindy is definitely influenced by the complexity of her environment. She demonstrates poorer performance in unfamiliar settings, with unfamiliar people, and with unfamiliar tasks. She tends to be overstimulated by a visually stimulating environment and performs best when seated at a small table and chair with limited objects present. She is generally underresponsive to voices and other environmental sounds although she demonstrates a fight or flight response to specific sounds like the vacuum cleaner. She does not appear to be bothered by lighting, smells, and temperature.
6.
Family Factors: Cindy's mother is a single parent who wants her child to be happy. She therefore, has a difficult time encouraging Cindy to communicate effectively or to participate in activities to enhance development if it is going to upset Cindy. Finding goals that were meaningful to this family was therefore, somewhat problematic. Dicussing the need for compliance for success in future occupations has been discussed and stressed. Overall, working on skills to enhance mother/daughter interactions has been most advantageous at this time.
(sorry for being a little too long winded and occasionally redundant)
Treatment:
1. To improve sensory processing: a) increase acceptance to sights, sounds, and feels for social, play, and ADL development. b) achieve a homeostatic level of arousal for learning. c) attend to task for age appropriate lengths of time. d) decrease negative reactions to noxious stimuli.
Strategies: sensory based strategies to calm/alert nervous system appropriately; adapt environment to decrease complexity; gradually introduce new sensory experiences, environments and people.
2. To improve motor skills: a) grasp patterns. b) bilateral coordination. c) handedness. d) strength. e) stability. f) muscle tone. g) endurance.
Strategies: develop arches in hands; grasp and release; bilateral activites; midline play; midline crossing; weightbearing; working at a vertical surface; walking and sitting on unstable surfaces; creating obstacles within the environment to step over, crawl under, etc.; gross and fine motor imitations; clapping to songs; two step clapping sequences; resistive materials.
3. To improve ADL's: independence in utensil use; drinking from open cup; dressing and undressing; fastens; washing; brushing teeth; hanging coat on hook; placing objects in and out of bookbag.
Strategies: scoop and dump dry materials like rice and beans; other tool use like wooden knife with velcroed foods or writing implements; drinking water from small dixie cup; dress-up with large clothing; doll dress-up; practice with zippers, buttons, and snaps; hang hood of jacket and bookbag on doorknob, try toothbrush without paste to begin with, try vibrating toothbrush, have Cindy brush her own teeth.
4. To improve social skills: for appropriate engagement and enjoyment from peer and adult interactions
Strategies: turn taking games; anticipation "ready, set.... " waiting for an engaging response; play groups; make-believe age appropriate scenerios; imaginative play to love or feed crying baby etc.; books on emotions
5. To improve cognition: to understand
Strategies: memory games, following simple directives; categories; labels; create age appropriate challenges that require problem solving, generalizing.
6. To improve language: to elicit functional communication.
Strategies: labels, identifying emotions, pointing, choosing, signing, pecs, nouns, verbs, pronouns, songs.
7. To improve behavior: for peace and success in all occupations.
Strategies: monitor complexity of environment, teach calming/alerting techniques as appropriate; prepare for events ahead of time via role playing, etc., use immediate reinforcement, tokens, use picture schedules to aid in anticipation of future events.
continually find that when I engage Cindy in silly play and movement activities, like swinging in a blanket, playing "airplane", or zooming across the living room in a laundry basket, that I can work on array of skills. Stopping and starting facilitates eye contact, communication, anticipation, and fun. We incorporate asking for more, i.e. "I want ____?", work on action words, i.e. "What are you doing?" Answer: swinging, flying, ect., or incorporate fast and slow. These activities are alerting and motivating and seem to naturally spark social and communicative reciprocity, an essential skill for most occupations throughout the lifespan.
continually find that when I engage Cindy in silly play and movement activities, like swinging in a blanket, playing "airplane", or zooming across the living room in a laundry basket, that I can work on array of skills. Stopping and starting facilitates eye contact, communication, anticipation, and fun. We incorporate asking for more, i.e. "I want ____?", work on action words, i.e. "What are you doing?" Answer: swinging, flying, ect., or incorporate fast and slow. These activities are alerting and motivating and seem to naturally spark social and communicative reciprocity, an essential skill for most occupations throughout the lifespan.
I think that several families in the Early Intervention Program are apprehensive of dreaming about their child's future. They are often wrapped up in a new diagnosis and the high demands of the here and now that they can not project what there child may be capable of at a distance point in time. They may underestimate their child's future skills based on current behaviors. On the other hand, they may fear disappointment from expectations that are too high. I think that it is important to discuss possible future scenarios with families, focusing on the child's strengths, and explaining how the mastery of current goals will lead to greater independence and success in the future. When a family can understand the meaning of current goals and dare to project future occupations for their child, they will be empowered to carry over with current goals, help to develop future goals, and advocate for their child based on their desire for their child's future.
