Running head: PAULS STORY

Pauls Story: An Evaluation and Intervention of a Child with Autism

Talia Bartolotta, Sydney Carnevale, Madeline Dunlap, Jennifer Godfrey, Davis Legaspi-David,
and Michelle Versten
Touro University Nevada

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Clients Performance in the Eight Occupational Areas

Paul is a 3-year-old boy diagnosed with Autism. His mother states that Paul demonstrates
various deficits when attempting to complete his activities of daily living (ADLs). He is able to
finger feed himself independently but requires assistance when using utensils. Utensil
manipulation is difficult, as he lacks the fine motor skills needed to properly grasp and
manipulate small items. As a soon-to-be 3-year-old, Paul should be able to use a spoon and a
fork independently with moderate mastery. Paul sometimes communicates that he has a soiled
diaper, but he does not possess age-appropriate daytime control. He is a good sleeper; he takes
daytime naps and sleeps through most of the night with few interruptions.
Paul is not able to participate in many age-appropriate educational activities. He lacks
the attention skills necessary to sit through story time. While at preschool, he struggles to stay
seated during circle time and requires maximum physical assistance to participate. Pauls mother
would like to enroll him in Gymboree but is hesitant to do so due to his lack of socialization
skills, required level of help, and high distractibility. She attempts to address some of Pauls
deficits on her own but is aware that he needs special education services in order to be
successful.
Paul is not consistently engaging in normative behaviors, nor is he mastering many
developmental motor milestones typical of his age. His mother states that Pauls gross motor
skills are comparatively immature to his peers. He is clumsy when running and playing. His
poor gross motor abilities indicate that he has poor body awareness, which can ultimately
manifest in decreased safety cognizance. These behaviors are indicative of a sensory need for
increased proprioceptive input. Paul also shows deficient recruitment and utilization of fine

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motor control, which affects his ability to play and participate in self-care activities. Low muscle
tone influences his ability to control and manipulate small objects and toys.
Paul often engages in sensory explorative play and wanders about the house seeking
sensory stimulation. Paul prefers solitary play and refuses to engage in associative play as
shown through avoidance behaviors such as dropping to the floor. He craves increased visual
sensory input, which may contribute to his inability to attend to objects for a long period of time.
He briefly attends to simple cause and effect toys. Paul requires hand-over-hand prompting to
engage in play activities for periods longer than five seconds.
Paul has significant social interaction skill deficits. He will not play with his brother nor
his peers and will engage in avoidance strategies. He has significant difficulty with joint
attention, as he does not attend to faces, take turns, or engage in cooperative interactions. Paul
requires significant verbal prompting to attend to his name. A physiological hearing deficit
should be ruled out before attention goals are implemented. He also avoids eye contact with
caregivers and peers for any extended amount of time. Paul has poor communication skills and
will only sporadically communicate, mainly relying on Picture Exchange Communication
(PECs) to address self-care needs. Increased use of the PECs and introduction of basic American
Sign Language (ASL) will allow him to better communicate and self-advocate when interacting
with others.
Characteristics of Movement, Postural Reactions, Tone and Reflexes Important to the
Client
Pauls overall gross and fine motor skills are not age appropriate. By the age of three, he
should be able to run balanced, climb, walk forward and backward with ease, and complete basic
ADLs. Paul appears clumsy when walking and climbing due to his low tone. Low tone also

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affects his ability to use utensils and bring food to his mouth. Muscle tone enables a child to
respond to outside forces through balance responses, righting reactions or protective reactions.
These reactions are often lacking in children with autism due to low tone (McNew, 2013). These
deficits may present as clumsiness, lack of coordination, lack of attention, gross motor skill
delay, and postural instability. Paul also has sensory processing deficits regarding body position
in space. Motor planning and praxis deficits in which the childs body cannot formulate the
proper motor response can create difficulty in the completion of basic ADLs and play (McNew,
2013).
Motor deficits are often due to poor motor planning, sensory processing deficits, atypical
reflex development and decreased tone. Motor planning challenges make it difficult for a child
to time, sequence, and execute a movement, such as reaching for objects, walking, or using
utensils to feed (Autism Speaks, 2012). Sensory processing difficulties often cause children with
autism to have difficulty modulating information from the environment, which can hinder their
decision making (Autism Speaks, 2012). The child may be hypo- or hyperresponsive to smells,
sight, sound, touch, or movement, which causes difficulty with information processing (Autism
Speaks, 2012). Challenging behavior may be the result of the lack of communication between
the child and caregiver. An important goal is to increase Pauls communication skills so that his
needs are being met, in turn reducing maladaptive behaviors and reducing his stress.
Sensory Integration, Sensory System Issues or Self-Regulation Issues of Client
Paul demonstrates weaknesses of his visual, tactile, and proprioceptive sensory systems.
Paul seeks visual stimulation such as watching the television, playing with toys with lights, and
looking for shadows, which shows that he may be hyporesponsive to visual stimuli. He shows
that he is hyporesponsive to proprioceptive input, as he lacks safety awareness and appears

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clumsy, and he seeks out this input through rough-and-tumble play. He also displays tactile
hyporesponsiveness and seeks out tactile input by being held by his mother during story time and
through oral stimulation by licking non-nutritive objects. Paul demonstrates poor self-regulation
as seen through avoidance behaviors, poor impulse control, and an inability to engage in social
time with his class.
Application of the PEOP Model
The Person Environment Occupation Performance model (PEOP) is used to increase the
well-being and quality of life for clients with or without disabilities. The goal of occupational
performance and participation can be modified to address the clients current state. These
modifications can vary based on levels of occupational performance (Brown, 2014). An
evaluation of the clients abilities need to be conducted to provide an intervention that supports
individual outcomes. In order for an individual to be successful in performing their meaningful
occupations, it is important to develop a goodness of fit between the demands of the
environment and the characteristics of the individual. The confluence of the person,
environment, and occupational factors will increase performance and expand as the individual
adapts or acquires new skills (Brown, 2014).
PEOP is client-centered and follows the top-down approach, making this model easily
adaptable to each individuals needs. Paul is still growing and will need adaptations as he
matures (Brown, 2014). The family has a desire for Paul to participate in activities outside the
home, especially at school. Paul uses PECs during meals, which should permeate into the
classroom and in his daily life. Adapting his school environment by providing technology, such
as the iPad, would stimulate his interest and increase his ability to communicate. Assistive
technology can also increase Pauls exposure to basic ASL, in turn promoting alternative

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methods of communication. The iPad can also be integrated into group activities in the
classroom. Not only would it encourage the development of social participation skills, but it
would challenge Pauls fine motor skills, cognitive functions, attention, and emotional regulation
skills.
Theories and Practice Models
Due to Pauls diagnosis, he shows deficits in social, emotional, and behavioral skills.
One practice model that would be applicable for Paul is the Psychosocial frame of reference.
This practice model will focus on both internal and external coping strategies for Paul to help
him manage his anxiety. If Paul learns how to communicate his needs more efficiently using the
PECs system and ASL, reduction in emotional and behavioral problems may result. The
Psychosocial frame of reference will also focus on social play for Paul to get him more socially
involved with his peers and the early intervention staff. Joint attention activities can improve
Pauls social-cognitive development as well as build the child-parent relationship.
Accommodation to the social world is highly mediated by child-parent joint attention
experiences. At his age, social play typically happens in the natural environment of the home
where joint attention, fine motor play, and imitation are integrated within the context of play
(Case-Smith, Law, Missiuna, Pollock, & Stewart, 2010).
Paul requires increased tactile, proprioceptive and visual stimulation which can addressed
through the Sensory Integration (SI) practice model. To address his need for excessive oral
stimulation, Paul will learn appropriate use of objects as opposed to licking non-nutritive items.
Paul also seeks out visual stimulation through television or lighted toys, however he only attends
to these items for a brief period of time. Another area to be addressed during SI treatment is
regarding his need for increased proprioceptive input, as he has poor body control leading to

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decreased safety awareness. Application of this model of practice will help keep Paul on track
with typical development and help him form adaptive responses from the sensory information
that he receives from external stimuli. Ultimately, the implementation of an individualized
sensory diet will increase Pauls participation in play and school.
The Behavioral frame of reference will be utilized to decrease the occurrence of
maladaptive behaviors and increase social interaction skills. A significant contributor to his
behaviors is his high distractibility, as seen during reading time with his mom and circle time
during school. A child Pauls age should be actively engaged in books with pictures, and
currently he is unable to do so. Within the Behavioral practice model, positive reinforcement is
used to reward a child for good behavior (Case-Smith, et al., 2010). Paul should be rewarded for
his positive behaviors but should also have consequences for his negative behaviors. For
example, if Paul attends to the pictures in the book, he should be praised and rewarded for this
positive behavior. Shaping is often used with this frame of reference to break down complex
behaviors into components and rewarding each behavior as it is achieved to create the desired
outcome behavior (Case-Smith, et al., 2010). This technique will be utilized by gradually
increasing the time Paul is required to engage in activities before he is given a reward, as is
discussed in his intervention plan.
Assessments to Evaluate Occupational Performance
Pauls occupational performance restrictions arise from hyporesponsiveness to sensory
input, poor social-cognitive skills, and motor delays. In order to completely evaluate Pauls
sensory, motor, and social interaction skills, two different assessment tools commonly used for
children with autism will be administered. These assessment tools are the Bayley Scales of
Infant and Toddler Development III (BSID III) and the Sensory Profile-2. The BSID III will

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assess Paul in the domains of cognitive, language, and motor skills (Bayley, 2006). Within the
language domain, receptive, expressive, and gestural communication will be tested. The motor
subtest evaluates both fine motor and gross motor skills. Due to Pauls clumsiness, lack of
communication, and need for hand-over-hand assistance in play activities, the BSID III will be a
valid norm referenced assessment to determine where he falls developmentally in comparison to
his peers.
The Sensory Profile-2 assessment tool will be used to identify how sensory processing
deficits may impact Pauls participation in his daily occupations. The Sensory Profile-2 is a
caregiver questionnaire designed to evaluate a childs sensory processing, modulation, and
emotional responsiveness within the contexts of the home, school, and community (Pearson
Education, 2014). The questionnaire is filled out by a teacher or caregiver who is able to observe
the child's responses to sensory input in their natural environment. This information can aid in
the development of a comprehensive, individualized treatment plan. The nature of both the
BSID-II and the Sensory Profile-2 will also provide insight into Pauls joint attention skills.
Five Problem Statements
1. Client requires minimal assistance to utilize utensils for self-feeding due to poor fine
motor control.
2. Client requires physical prompting to engage in structured play activities for an extended
period of time due to poor attendance to tasks.
3. Client requires verbal prompting to sustain eye contact with strangers due to poor social
interaction and joint attention skills.
4. Clients desire to engage in solitary play results in limited opportunities for peer
engagement and the development of age-appropriate social skills.

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5. Client is unable to express self-care needs and wants due to limited language skills.
Goals of the Family/Caregivers
The family has different sentiments regarding Pauls current ability levels and
prospective treatment options. Mom believes that Paul is falling behind in key developmental
areas such as motor skills, social cognition, and education. Pauls father does not believe his son
has any developmental delays, rather that he will grow out of the behaviors. Despite the
incongruences, some prominent trends emerged from the occupational profile that helped to
delineate specific areas of concern. These concerns included:
-

Pauls unwillingness to engage in social activities outside of the home. His poor
communication skills also makes social interaction difficult.

Paul often engages in solitary play and exhibits avoidance behaviors when prompted to
play with his brother or his peers. She hopes that he can gain the necessary social and
coping skills to engage in appropriate play with others.

Paul exhibits maladaptive behaviors during his time at preschool, which requires his
teacher to use hand-over-hand prompting to keep Paul engaged in the activity.

Paul has poor joint attention which is expressed through his unwillingness to make eye
contact, poor attendance to faces, and unwillingness to take turns with peers and
caregivers.

She wishes to improve gross and fine motor skills in order for Paul to engage in self-care
and play activities with greater independence.

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Occupationally-Based Goals

The following goals have been created to address some of Pauls developmental deficits that
greatly interfere with his ability to engage in play and school activities. Based on the concerns
and goals of the family as well as the available resources, the following goals have been written:
Client will actively participate in age-appropriate play activities independently with his
peers and caretakers by April 31, 2015.
Client will be able to recruit and utilize the appropriate fine motor skills necessary to
independently complete 4 out of 5 of his daily play and self-care activities by May 31,
2015.
Client will be able to attend to 4 out of 5 of his preschool activities with minimal
assistance by April 31, 2015.
Goal Objectives and Activities
Three goals have been established to help Paul improve in the areas addressed by his
family. The first goal states that he will actively engage in age appropriate play independently
with his peers by May 31, 2015. A typical 3-year-old child should engage in some aspects of
associative play. Another goal regarding play behaviors include that the client will participate in
joint attention activities with his peers or brother, while also sharing materials, with two verbal
prompts by March 31, 2015. The first activity will be to have Paul build with large blocks while
sitting next to a peer or a caretaker who is also building with the same set of blocks. The blocks
should be in a single bin so that Paul has to interact with his peer when getting his materials.
The second activity to increase associative play will involve the completion of a wall painting
mural with peers or with caregivers. A piece of paper can be taped to the wall and then Paul and
his peers can work on a mural together.

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The second objective will incorporate both motor and joint attention skills. One activity
will include the use of a bubble wand. Paul will be encouraged to take turns making and then
popping bubbles. The use of colored bubble soap or soap with sparkles would also incorporate
his desire for increased visual input and help sustain his attention. Joint attention activities can
also be incorporated into his bedtime routine when his mother reads to him. When she reads to
him, she can verbally prompt Paul to point to the different pictures. Use of a book with textured
pictures would be particularly useful to increase his engagement during story time.
The second goal states that Paul will be able to recruit and utilize the appropriate fine and
gross motor skills necessary to independently complete 4 out of 5 of his daily play activities by
May 31, 2015. The two objectives created to help him reach this goal are (1) the client will be
able to engage in a fine motor play activity that uses a neat pincer grasp with minimal to
moderate assistance and complete at least 75% of the activity by March 31, 2015, and (2) the
client will engage in fine motor grasps and gross motor object manipulations that allow him to
engage in age appropriate self-care activities with minimal assistance by April 31, 2014. To help
facilitate the development of his neat pincer grasp, Paul can play with a Lite-Brite and complete
at least 75% of a picture. Hand-over-hand assistance can be used to encourage Paul to use a neat
pincer grasp as he places the pegs into the game.
In order for Paul to develop the necessary fine motor grasps and gross motor object
manipulations needed to properly use utensils, he will be given a large handled spoon and be
encouraged to use the spoon to self-feed during meal times with assistance from caregivers. The
caregivers will provide verbal and physical cues to ensure that the appropriate grasp is used.
Another activity that will be implemented for fine and gross motor skill use is to have Pauls

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parents encourage him to help uncap a toothpaste tube and squeeze a small amount of toothpaste
onto a toothbrush during his morning or evening routine.
The third goal states that he will be able to complete at least 75% of his preschool
activities with minimal assistance by April 31, 2015. The first objective will require that the
client be able to sit during story time/circle time for at least ten minutes and attend to activity
with minimal to moderate assistance by February 31, 2014. Increased sitting time will be
encouraged by having Paul help choose the book or circle time activity. He should sit next to the
teacher so they can provide prompting as necessary. Time in the circle should be increased by
one minute intervals until he can participate for at least ten minutes. To increase the amount of
time seated, the teacher can prompt the class to do a brief physical activity right before circle
time. This can consist of activities such as marching or carrying bean bags, pillows, etc. to the
circle to sit on.
The second objective is that by March 31, 2014, Paul will be able to sit at his desk and
attend to an individual structured school activity for at least five minutes with no more than two
verbal or physical prompts. While sitting tabletop, he will be given a craft activity that requires
him to glue small items to a piece of paper, such as macaroni or beads, with assistance from the
teacher. A second activity to accomplish this will be completed in a similar manner as the
previous one. While sitting tabletop, Paul can complete the pages from a coloring book with
objects that he is familiar with. Each time he wants a new color, he must ask the caregiver,
teacher or peer for the color that he would like.
Treatment Session Based on OT Goals and Objectives
The most beneficial setting for Paul to receive OT treatment would be in a naturalistic
environment, such as home or school. Pauls treatment sessions will take place in a Motor Skills

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lab which will be modified to mimic Pauls natural environment. The treatment environment
will have key items such as tables, chairs, age appropriate toys, art supplies, and eating utensils.
These items will be used towards strengthening Pauls gross motor, fine motor, and attention
skills. An open layout with the blue floor mats will also be set-up for safety purposes. Pauls
family will receive educational resources about his diagnosis with information regarding the best
possible treatment for Paul. An open line of communication through telephone or email will be
set up to address any questions that Pauls family might have.
It would be beneficial to have his younger brother or a family member present during the
treatment sessions so that Paul will become more accustomed to engaging with others. A home
program will also be assigned for Paul so that he can further develop his skills with the help of
his family. In addition, his teachers and Gymboree instructors will be given recommendations
on how to better communicate with Paul so that he can actively participate in all of the activities.
S.O.A.P
S: Subjective
Client shy upon arrival but quickly warmed to therapist. Mom reports client made eye
contact with father and attended to name 2x in the past week.
O: Objective
Client participated in a 45-minute OT morning session at Touro University Nevada to
work on joint attention and fine and gross motor skills. Began session by jumping on trampoline
with handlebar for 5 min. Held handlebars with both hands. Jumped w/both feet for 8
consecutive jumps. Verbalized wow 1x. Transitioned smoothly and independently climbed
into swing. Fair postural control on swing. Held rope handles with both hands for 2 min. of
swinging. Client sat tabletop for Lite-Brite activity for 8 min. Used lateral pinch to place pegs

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into board w/mod A to push pegs in fully. Verbalized more 3x in response. Independently
transitioned to floor and kicked a medium size ball at target. Knocked down tower 6 ft away, 1/5
attempts. Cried during transition for 3 min before he calmed enough to participate in next
activity. Took turns playing with bubbles with 3 verbal prompts for 5 min.
A: Assessment
Clients difficulty with transitions and emotional regulation limits his abilities to
participate in play and social activities. Clients low tone and poor trunk stability limit his ability
engage in appropriate gross motor play. Clients ability to engage in Lite-Brite activity indicates
progress of sustained attention. Increased eye contact with others indicates progress for social
skills. Clients willingness to engage in joint attention play activities shows potential for age
appropriate play with peers. Clients ability to ask for more pegs indicates potential for
improved communication.
P: Plan
Client will continue to receive skilled OT services 2x/week for 45 min to improve social
participation and motor skills. Client will begin session by jumping on the trampoline to provide
proprioceptive input to organize his body. Client will improve his joint attention during
associative play by increasing time intervals spent playing different activities that require social
interaction. Resources will be provided for a home play program that will incorporate Pauls
brother and parents in order to encourage appropriate play behaviors and increase joint attention
skills.
Post-Discharge Plan and Recommendations for the Family/Caregivers
Paul has shown to be hyporesponsive with his proprioception, oral stimulation, and
auditory stimulation. A post-discharge environment for Paul should be one that implements the

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idea by Woo and Leon (2013) of an enriched sensorimotor environment in order to prevent a
lack of stimulation to Pauls senses. Woo saw that most of her child participants in this type of
environment had a significant improvement in their cognition and overall behavior. Based on
these results, recommendations to increase Pauls sensorimotor engagement throughout the day
with multiple age appropriate stimuli would be beneficial. Having Paul walk around his home
wearing a weighted backpack or having him jump on a trampoline would address his need for
proprioceptive input. To address Pauls need for oral stimulation, his family can give him
different textured food to chew on, a thin krazy straw for resistive sucking when he drinks,
chewy tubes, or toys that require Paul to blow, such as a whistle or kazoo. Resources regarding
joint attention activities will be given to the family that they can do at home together. These
strategies will constructively allow Paul to have to utilize multiple senses while simultaneously
building his attention skills.
3 Journal Article Justification
With Pauls multiple areas of sensory integration issues, a sensory integration approach
would be appropriate to implement during his intervention. According to a study by Preis and
McKenna (2014), children with autism who participated in the study showed improved
communication skills; specifically spontaneity, complexity of utterance, and engagement during
or after receiving sensory integration therapy. Paul would be able to engage with others more
effectively with improved communication skills. Sensory integration would also allow Paul to
organize his body in such a way that learning new PECs and basic signs would be appropriate.
In addition to working on sensory integration, an intervention that works on fine and
gross motor skills would benefit Paul not only because his fine and gross motor skills are not
currently age appropriate, but because improving his overall sensorimotor skills would help Paul

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improve his self-care skills. In a study by Jasmin et al. (2009), fine motor skills showed a high
correlation with daily living skills, or self-care skills, in preschool children with autism spectrum
disorders (ASD). Because sensorimotor deficits affect self-care skills in children with ASD,
interventions should aim at improving and supporting the development of sensorimotor skills
(Jasmin et al., 2009, p. 231). Working on Pauls motor skills during his therapeutic intervention
is important in addressing his therapy goal of utilizing fine and gross motor skills to more
independently participate in play and age appropriate self-care activities.
An intervention using a behavioral approach would also be appropriate in addressing
Pauls maladaptive behaviors. A study by Fulton, Eapen, rnec, Walter, and Rogers (2014)
studied preschool-aged children with autism and looked at the effectiveness of the Early Start
Denver Model (ESDM), a behavioral approach, in reducing their maladaptive behaviors. The
ESDM works on building communication abilities and social attention, which teaches children
adaptive ways of getting their needs met (Fulton et al., 2014, p. 2). This behavioral approach
focuses on replacing unwanted behaviors with more appropriate behaviors that meet the childs
needs using positive behavior supports and reinforcement strategies. The goal is to promote
adaptive behaviors and independent functioning through an intervention based in play and
natural daily routines (Fulton et al., 2014). The results showed that the maladaptive behaviors in
the children with autism significantly decreased after the ESDM intervention (Fulton et al.,
2014). Based on these findings, using a behavioral intervention could benefit Paul by improving
his adaptive behaviors, communication, and social skills. This would help him meet his needs
and participate more actively in his preschool program, ultimately promoting more successful
overall development.

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References

Autism speaks family services challenging behaviors tool kit. (2012, January 1). Retrieved
December 29, 2014, from
http://www.autismspeaks.org/sites/default/files/challenging_behaviors_tool_kit.pdf
Bayley, N. (2006). Bayley scales of infant and toddler development, screening test (3rd ed.). San
Antonio, TX: Pearson.
Brown, C. E. (2014). Ecological models in occupational therapy. In B. A. B. Schell, G. Gillen, &
M. E. Scaffa (Eds.), Willard & Spackmans occupational therapy (12th ed., pp. 494-502).
Philadelphia, PA: Lippincott Williams & Wilkins.
Case-Smith, J., Law, M., Missiuna, C., Pollock, N., & Stewart, D. (2010). Foundations for
occupational therapy practice with children. In J. Case-Smith & J. OBrian (Eds.),
Occupational therapy for children (6th ed., pp. 22-55). St. Louis, MO: Elsevier.
Fulton, E., Eapen, V., rnec, R., Walter, A., & Rogers, S. (2014). Reducing maladaptive
behaviors in preschool-aged children with autism spectrum disorder using the Early Start
Denver Model. Frontiers in Pediatrics, 2(40), 1-10.
Jasmin, E., Couture, M., McKinley, P., Reid, G., Fombonne, E., & Gisel, E. (2009). Sensorimotor and daily living skills of preschool children with autism spectrum disorders.
Journal of Autism and Developmental Disorders, 39(2), 231-241.
McNew, S. (2013, May 2). Autism exercise topics: Proprioception and sensory. Retrieved
December 29, 2014, from http://playthroughautism.com/autism-exercise-topicsproprioception-and-sensory
Pearson Education. (2014). Clinical psychology. Retrieved from
http://www.pearsonclinical.com/psychology/products

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Preis, J., & McKenna, M. (2014). The effects of sensory integration therapy on verbal expression
and engagement in children with autism. International Journal of Therapy and
Rehabilitation, 21(10), 476-486.
Woo, C. C., & Leon, M. (2013). Environmental enrichment as an effective treatment for autism:
A randomized controlled trial. Behavioral Neuroscience, 127(4), 487-497.