CASE STUDY

Case Study
Jenna Babcock, Justin Christman, Emily Matthews,
Gary Pearson, Ian Sande, and Nicole Sellers
Touro University Nevada

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Occupational performance

Activities of daily living (ADLs)

Zakary requires maximum assistance for dressing and bathing tasks and he is not
showing any interest or motivation to participate in these two daily activities. He also still
requires wearing a diaper due to his inability to manage his bowel and bladder. Due to his
minimal self-regulation skills, he has difficulty with self-feeding, sleep routines, play and
socialization skills. He has transitioned from a bottle to a straw cup but does not like any wet or
soft foods. He does not have any difficulty with functional mobility; he is able to walk, run, and
climb on furniture independently.
Instrumental activities of daily living(IADLs)
N/A
Education
Due to Zakarys age of 2 years, 7 months, he is not in preschool yet; also, due to his
inability to self-regulate and manage his ADLs and social interactions, he would most likely
benefit from occupational therapy when in pre-school and an individual education plan (IEP).
Work
N/A
Play
Zakary is not interested in age appropriate toys and has demonstrated decreased play
skills. He has difficulty participating in community play groups or park outings with his sister.
He does not transition well in between activities and once he becomes upset he will have a
meltdown lasting up to one hour. He does not interact at all with his sister or any other kids his
own age.

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Leisure
N/A
Social participation
His mother is very concerned about his decreased social skills with others and would like
to see him interact with his twin sister. He demonstrates poor eye contact and minimal response
to his name. However, when upset he does call for his Mama and maintains minimal eye contact
when engaged in swing activities for occupational therapy.
Rest and sleep
Zakary currently takes one daily afternoon nap but wakes up several times during the
night and his mother has to soothe him with rocking motions. He also taps his head on the edge
of his crib to fall asleep and demonstrates adverse reactions to touch.
Characteristics of movement, postural reactions, and/or reflexes
Zakary demonstrates poor postural control and decreased limb awareness. When placed
in the prone position, he demonstrates poor control and will squeal followed by a tantrum for an
hour. To decrease poor behavioral output, therapists place Zakary on his favorite swing and the
therapist applies deep compression with heavy input. This routine is done quite often in order to
get Zakary to complete tasks of daily living, play and social interaction.
Sensory integration and self-regulation issues
Zakary seeks for proprioceptive and vestibular input to help him with modulation skills.
When in the clinic, he performs wrist rotations and high pitch squeals when the therapist requests
him to participate in task completion activities. He has a high threshold for arousal level and has
difficulty with sensory modulation. He demonstrates hyper-responsiveness to tactile and oral
input; however he responds well to increased movement activities and rhythmic input.

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Therapists work with Zakary on his proprioceptive and vestibular input by having him perform a
series of swinging activities, specifically the Lycra swing, along with deep compression followed
by tasks involving tactile and oral input. A specific deep compression he enjoys is being
squeezed by pillows. At home, he flips open books close to his face and bumps into walls or
furniture. When placed in his crib, he taps his head on the crib to fall asleep and also has adverse
reaction to touch. He walks on his tip toes, does not like to wear socks and shoes and walks
barefoot on rocks.
PEOP model
The Person, Environment, Occupation, and Performance model (PEOP) is a dynamic
model that describes the collaborative nature of the person, occupation, environment, and
performance as they influence the human being (OBrien, 2012). The person factors include the
physical, social, and psychological aspects of a person. Zakary is a 31 month year old toddler
diagnosed with autism who has a twin sister. He requires maximum assistance for dressing and
bathing tasks. He demonstrates poor social skills and resists self-feeding of any wet or soft foods.
He is not interested in age appropriate toys and demonstrates decreased play skills. Zakary
enjoys spinning in circles and flipping open books very close to his face. His family would like
him to be more social and play with his twin sister as well as engaging in tasks such as bathing
and dressing. Zakary's environmental factors are the physical and social supports and those
factors that interfere with the his performance. Zakary's physical supports are proprioceptive and
vestibular input. The childs social supports are his mother, sister, behavioral and occupational
therapists, and speech practitioner. The factors that interfere with Zakary's performance are selfregulation skills. Zakary's occupations are sleep and play.

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Zakary has most difficulty with self-regulation. This adversely affects all of his
occupations. The family wants Zakary to improve his self-regulation skills and play with his
twin sister. The intervention should be geared towards reaching the family's goals. The
occupational therapist should adapt and modify the environment based on Zakary's performance
range. This can be done by providing an adequate sensory diet throughout the day to fulfill
Zakary's sensory needs.
Theories and practice models/frame of reference (FOR)
Zakary would benefit the most from Dynamic Systems Theory. This theory would apply
to Zakarys interaction among sensory, cognitive, neuromusculoskeletal, and environmental
systems. Dynamic systems theory would allow occupational therapists to facilitate intervention.
When developing goals for self-feeding, dressing, bathing, hand skills and play it is important to
focus intervention on his balance and stability. He demonstrates poor postural control when
sitting and has limited motor skill in part because the foundation for carrying out skillful
movements is not well developed.
Sensory Integration will also be important in helping Zakary with his occupations.
Zakary has demonstrated poor self-regulation skills which are affecting his ADLs. Zakary has an
aversion to soft or wet food and also taps his head on his crib to fall asleep. He walks barefooted
on rocks, dislikes wearing shoes or socks, and walks on his tip toes. He seeks proprioceptive and
vestibular input. He enjoys spinning in circles, looking at books close to his face, and bumping
into walls and furniture. He is sensory seeking to help with modulation skills. By introducing
Zakary to Sensory Integration he will be able to improve his modulation and praxis skills, and
gain an ability to better regulate sensory information. Zakarys increased ability to regulate
sensory processing will help him interact with other peers and play with age appropriate toys.

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He will also be able to regulate his increased need for proprioceptive and vestibular input.
Zakarys aversion to certain foods will also be remediated.
Implementing frame of references, such as, sensory integration, compensatory and
psychosocial would also benefit Zakary.
Assessment
The Transdisciplinary Play-Based Assessment (TPBA) is a criterion-referenced
evaluation which measures a childs cognitive, social-emotional, communication, and
sensorimotor skills. The TPBA is used as an observation tool to evaluate the child. The TPBA
can be used with children from birth to 6 years of age. The assessment is performed in the childs
natural environment to allow for higher levels of play and exploration.
Functional problem statements
1. Zakary requires maximum assistance to dress himself due to lack of interest and
motivation.
2. Zakary requires moderate assistance in self-feeding due to dislike of soft or wet foods.
3. Zakary requires moderate assistance when sleeping due to waking up multiple times
during the night.
4. Zakary requires maximum assistance when playing and socializing with his sister due
to the childs inability to communicate and interact with others in an interactive
environment.
5. Zakary requires maximum assistance in playing with age appropriate toys due to an
inability to plan and manage the performance of an age appropriate activity.

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Caregiver goals

1. Zakary's family would like him to be able participate with moderate assistance in
ADLs including dressing, toileting, and feeding.
2. Zakarys family would like him to engage in a higher level of social play with his sister
and other children.
3. Zakarys family would like Zakary to be able to verbally express his needs more
clearly to help prevent negative outbursts and better transitioning between activities.
4. His mother would like to see an increase in play with age appropriate toys and play
skills.
5. His mother would like to enhance the childs self-regulation skills during sleep routines
to allow for a full nights sleep.
COAST goals, objectives, and activities
1. Zakary will demonstrate improved self-help skills in feeding and dressing with
moderate assistance trials within 6 months.
1a. Zakary will pull up pants with moderate assistance 50% of the time within 6
weeks.
1. Therapist will create video model of donning and doffing different
articles of clothing for Zakary to watch to practice dressing. The video
can be created through an app, found on a website, or created by
videoing Zakary himself getting dressed.

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2. Zakary will don pillow case on feet, with assistance as needed, and
partake in a potato sack race through a therapist designed, novel
obstacle course to improve self-help dressing skills.

1b. Zakary will self-feed soft and wet foods (such as bananas, yogurt, oatmeal,
and applesauce) with moderate assistance 75% of the time within 6 weeks.
1. Zakary will draw in pudding with fingers and create pudding art on
paper at table top to reduce sensitivity to soft textured foods. Paint
brushes, paper towels and cookie cutters will be provided to use in play
and to transfer pudding to paper for pudding art.
2. Zakary will use cookie cutters to cut shapes out of tray of jello to reduce
sensitivity to soft, wet foods. Desired food or toys can be placed into
the jello to promote finger play.
2. Zakary will participate in daily self-regulation activities in order to improve his
compliance with routine-based activities at home as reported by parents within 6
months.
2a. Zakary will utilize a sensory diet in the home environment to prepare for his
daily routines with set up assistance and cueing as needed 5/7 days of the
week as reported by parents.
1. Therapist and caregiver will establish a bedtime routine with
parent/child stretching exercises to give proprioceptive and tactile input
to help with sensory modulation. The routine can consist of stretching

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techniques, deep pressure exercises, and a bath time routine. This will
require the assistance from a caregiver and is to be performed each
night before bed.
2. Therapist will introduce head, shoulders, knees and toes song to
Zakary and caregiver to be utilized at home before participating in daily
routines. Assistance will be needed in singing the words of the song and
modeling body positions to help with coordination and motor planning
issues. I video or audio track of the song may be utilized for assistance.

2b. Zakary will engage in structured sensory activities for 5 minutes to promote
calm state and increase attention to task in 50% of trials with minimal cueing
in 6 weeks.
1. Allow Zakary to choose between two swings to swing on for 5 minutes
before tx session and between activities as needed to promote calm
state and increased attention. The swings can be of different nature,
providing different feedback, such as a lycra swing for proprioceptive
input and a platform swing for vestibular input.
2. Zakary will sit or lay prone on scooter board and use hands to move
scooter board and self into a stack of foam blocks (scooter board
bowling) to increase proprioceptive input, decrease arousal levels and
increase attention. Assistance can be provided to help Zakary with
motor planning and coordination of UE in moving towards the target.

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The speed, distance from target, size of block target, and amount of
impact can be adjusted according to Zakarys preference or need.

3. Zakary will improve purposeful play for greater social participation with
peers/therapists/parents while also furthering his communication development 50% of
the time with cuing within 6 months.
3a. Zakary will improve on simple game and reciprocal play with toys/stuffed
animals in 50% of trials in 6 weeks.
1. Zakary will participate in play with the therapist with sock/finger
puppets to increase peer interaction and appropriate communication
skills. Play can take place during calm and attentive state such as on a
swing or after participating in sensory modulation activity. Therapist
may need to provide max A in story modeling to engage Zakary in
reciprocal play.
2. Zakary will play Twister alternating turns with therapist to increase peer
interaction while providing proprioceptive input, increasing bilateral
coordination and limb awareness. The rules of the game can be
adapted for age, motor skill, and cognitive appropriateness. Assistance
in motor planning and coordination for proper placement may be
needed. Music may be played during activity to help create rhythm of
movement.
3b. Zakary will increase communication by indicating his choice of play activity
with minimal cueing 75% of trials within 6 weeks.

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1. Zakary will be given a choice of two of the play activities to be
completed that session to communicate his preference as to which he
will complete first. If he will not communicate his preference, the
therapist will indicate which will be done first and which will be done
at a later time.
2. Therapist will create a visual schedule of three play activities to be
completed that session and allow Zakary to choose the activity order.
Pictures of the three activities will be attached to a board with velcro
for Zakary to arrange in a desired order. If a decision is not made
independently, the therapist will arrange the activities providing a visual
model of events for Zakary.
Treatment plan

Zakary will arrive for tx at the outpatient SI clinic and begin participation in scooter
board bowling for 15 minutes to provide proprioceptive input, decrease arousal, and increase
attention. Next, he will choose between two swings to participate in for 5 minutes as a transition
decreasing arousal and increasing attention. We will then transition to a table top pudding
activity involving picture drawing and paper art with fingers and hands for 15 minutes. Zakary
will again choose a swing to transition to for 5 minutes. The next 15 minutes will be spent
practicing donning a pillowcase on LE and completing an obstacle course potato sack race to
improve self-help skills and grasp strength for dressing.
SOAP note
Subjective

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Zakary entered into tx session energetic, but hesitant to begin therapy. Zakary
transitioned through the tx session with varied behavior appropriateness.
Objective
Zakary participated in a 60 minute outpatient OT session focused on improvements in
sensory modulation, self-help skills, and appropriate social skills and communication for
increased involvement in functional play with a peer. Zakary demonstrated a need for repetitive
visual and verbal cues to maintain attention to tasks 75% of the time. He was able to follow 2-4
word command sentences needing physical and verbal cues to make appropriate eye contact.
Proper sitting posture was maintained throughout tabletop activities secondary to verbal and
physical cues. He is working on using his lateral pinch strength for play and self-care activities.
Zakary demonstrates a weak lateral grasp, needing mod HOH A for dressing activities of LE. He
demonstrates adequate UE strength but needs mod A in motor planning. Verbal cues were needed
90% of trials to participate in pretend play.
Assessment
Zakarys poor attention during the tx session limits his ability to participate in functional
peer play and social engagement. Limited fine motor strength with fatigue and minimal limb
awareness restricts his ability to I perform self-care and ADLs interfering with developmental
milestones and preparation to enter school. Progress of grasp strength is being made with
reduced assistance needed during tasks. His focus is progressing during tabletop activities
reducing the time of transitions by half indicating good potential outcome for goal attainment.
Zakary demonstrates improvements in functional use of communication to demonstrate wants
and will benefit from continued skilled OT intervention to increase developmentally appropriate

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communication skills, sensory modulation, and attention to improve occupational engagement,

and age appropriate self-care.
Plan
Continue to treat Zakary 1x/wk for 60 min sessions for 6 months to increase
developmentally appropriate communication skills, self-help skills for ADLs, and decrease
amount of verbal cues needed to maintain selective attention during task. Plan to address limb
awareness, and trunk strength and endurance with sensory-based activities including peer
interactive play.
Specific recommendations and post discharge environment
Zakary will be discharged to his home setting. It will be recommended that the parents
continue using the sensory diet daily. They should continue working on dressing skills and ADLs
in home environment utilizing sensory modulation, arousal and attention exercises beforehand to
help Zakary with sensory regulation. There should be a continuation of feeding skills,
introducing new foods in the soft and wet textures, allowing 10-15 trials with each food before
ruling it out of his diet.
Justification of treatment based on research
According to Kuoch and Mirenda (2003), the use of social story interventions for young
children with autism spectrum disorders benefited and improved to individual changes in routine
and social skills as alternatives to problem behaviors. When the social social story intervention
was withdrawn, reversal of the effect of treatment did not occur and the problem behavior
remained low. This intervention would be beneficial for Zakary while learning appropriate

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communication skills and practicing self-help skills such as dressing and feeding. Since he is
near the preschool age, the social stories would help him in the educational settings as well
(Kuoch & Mirenda, 2003).
Piazza et al. (2002) found that presence of preferred food in combination with non
preferred food helped participants eat. Interventions for Zakary include his tactile aversions
regarding food. Implementing pudding along with other nonpreferred foods during interventions
could promote him eating more suitable table foods appropriate for his age. Allowing Zakary to
play with the pudding performing multiple activities such as finger manipulation would allow
him to address his tactile defensiveness (Piazza, Patel, Santana, Goh, Delia, Lancaster, 2002).
Inclusion of preferred food into the jello activity would model the ideas of Piazza et al. to
promote eating of soft, wet foods.
Amos (2013) looked at autism and the research concerning the roles of rhythm and
timing in regard to perception and coordination of different types of sensory information.
Attending to rhythm and timing may offer new, more insightful ways to respond to experiences
and social interactions (Amos, 2013). Wimpory et al. found interventions that can be used to
overcome social timing issues and build a scaffold for emergence of communication and
language using Musical Interaction Therapy. Based on reports by parents of children and some
adults diagnosed with autism spectrum disorder (ASD), several intervention strategies were
presented. Strategies such as: emphasizing reciprocal relationships; supporting exploration of
preferred interests and expand them in directions that others can share; valid practice in
meaningful and typical experiences; dynamic systems encouraging flexibility and support of
experiences with different solutions to a task for adaptation skills; creation of safety and reduced
anxiety using techniques to relax the body and mind with deep breathing, yoga and mindfulness;

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music, rhythm and dance to explore emotions and scaffold communication; and exploring
adjustments to environment, interactions and self-regulation to enhance praxis are suggested for
this population (Amos, 2013). Interventions for Zakary include singing Head shoulders knees
and toes as part of his sensory diet to help decrease his arousal and increase his attentiveness to
prepare him for activities. Movement based activities such as Twister can be utilized to work on
social timing and communication issues for Zakary as well.

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References
Amos, P. (2013). Rhythm and timing in autism: learning to dance. Frontiers in Integrative
Neuroscience, 7(27). doi: 10.3389/fnint.2013.00027
Case-Smith, J. (2010). Occupational therapy for children (6th ed.). St. Louis, Missouri:
Mosby/Elsevier.
Kuoch, H., & Mirenda, P. (2003). Social story interventions for young children with autism
spectrum disorders. Focus on Autism and other developmental disabilities, 18(4), 219227.
OBrein, J. C., & Hussey, S. M. (2012). Models of practice and frames of reference. In K. Falk &
J. Gower (Eds). Introduction to occupational therapy (4th ed., pp. 136-137). St .Louis:
Mosby.
Piazza, C. C., Patel, M. R., Santana, C. M., Goh, H. L., Delia, M. D., & Lancaster, B. M. (2002).
An evaluation of simultaneous and sequential presentation of preferred and nonpreferred
food to treat food selectivity. Journal of Applied Behavior Analysis, 35(3), 259-270.