OCCT 506: Clinical Reasoning about Occupation Form #5 Student: James Stewart Activity: Sunday School Date: October

17, 2012

Client-Activity Intervention Plan Directions: This assignment is to be completed individually. Choose someone that has a disability and observe them performing an occupational activity. Complete the following sections based on your observations. Clients Occupational Profile Gabe Wilson is a 10-year old boy with severe autism. He has communication, cognitive, social, and emotional impairments as well as sensory dysfunction. He can repeat words, but has difficulty saying his own words and sentences. He can read on a first grade level, but has difficulty with reading comprehension. He can sit with peers for an hour when provided goldfish at one-minute intervals. He can express his anger and frustrations, but is unable to regulate that anger and frustration. He seeks proprioceptive and vestibular sensations through excessive jumping, running, spinning, rough and tumble play, squeezing and theraputty. Gabe also enjoys swimming, drawing, and bouncing on an exercise ball. He is motivated by candy, goldfish, and the sensory activities already listed. Gabe lives with both of his parents and two older brothers. His father is a lawyer and his mother is a homemaker. Both of his brothers, age 16 and age 14, also have autism. The oldest brother, Tim, has high functioning autism. Most of his impairments are social in natural. Gabes other brother, Gary, has all the same impairments as Gabe but in a more serve form. Gabe was involved in early intervention services since age two and then was in special education preschool. He is now in a special education classroom. He also attends the LDS Church with his family on Sundays. He frequently has behavior outbursts (running, screaming) when he attends his Sunday School class. His behavior

Client Information

(Modified from Hersch, Lamport, & Coffey, 2005)

OCCT 506: Clinical Reasoning about Occupation Form #5 happens more often when he is tired, but tends to have fewer outbursts when motivated by goldfish. His parents are seeking services so that these behaviors decrease and he can participate in class. His parents first priority is to decrease the amount of screaming during class. Referral from parent: Jenny Johnson (Mother) 1432 American Pacific Dr. Henderson, NV 89074 702-555-5968 Reason: To reduce behavior outbursts during Sunday School class Diagnosis of client: Autism Physician: Peter Hostetler 563 Eastern Ave. Henderson, NV 89076 702-888-0990 The goal of the activity is to increase the amount of time that Gabe can attend class. The focus is to decrease the amount of times that he runs and screams during Sunday School class and increase the amount of time that he sits quietly in his chair. He will be rewarded with goldfish for sitting quietly in his chair. This will allow Gabe to participate in Sunday School activities with his same age peers. Within 12 Sundays, Gabe will participate in class by sitting in a chair next to a classmate for the whole class period (45 minutes) without running or screaming. Within 4 Sundays, Gabe will participate in class by sitting in a chair in the classroom for 10 minutes without running or screaming. The practitioner will perform all of the tasks required for preparation of the activity. These tasks include creating a visual reminder, setting up chairs in the Sunday School classroom, setting up chairs in a preparation room, obtaining goldfish and a stopwatch, and educating all involved about the activity itself. The visual reminder will consist of a picture of someone sitting quietly in a chair and a picture of a goldfish underneath it. The classroom teacher and class will not help with the

Referral Information

Describe the goal of the activity and why the client is completing it Activity Description

Long-Term Goal Intervention Goals Short Term Goal Practitioners role

Activity Preparation

Personnel required to complete the

(Modified from Hersch, Lamport, & Coffey, 2005)

OCCT 506: Clinical Reasoning about Occupation Form #5 preparation preparation, but the practitioner will need to inform and educate them on their roles in the process. The practitioner will need to explain about what is happening and why as well as discuss possible behavioral responses from the client. The practitioner will need to explain to them that the client usually has two responses: running and screaming. The appropriate way for them to respond is to ignore the behavior. Similarly, the client will not help in the preparation, but the practitioner will need to educate the client on the activity. This is helpful, especially for clients with autism, so that he can know what to expect. Also he will understand that he will be rewarded for sitting quietly in his chair during class. The practitioner and the client will practice in a separate room in preparation for the actual activity. 1. The practitioner will create the visual reminder, which will take about 5 minutes. 2. The practitioner will obtain goldfish and a stopwatch. This time will vary depending if the practitioner already has these items or needs to purchase them. 3. The practitioner will set up chairs in the Sunday School classroom, which will take about 2 minutes. 4. The practitioner will set up chairs in the preparation room, which will take about 1 minute. 5. The practitioner will educate the Sunday School teacher and the clients classmates about the activity as discussed previously, which will take about 5 minutes. 6. The practitioner will educate the client about the activity as discussed previously, which will take about 5 minutes. 7. The practitioner and the client will practice the activity in the preparation room, which will take about 5 minutes. Two classrooms will be needed in the church. First, a preparation room is needed where the practitioner and the client can practice the

Required preparation steps and time for each step

Required place and space

(Modified from Hersch, Lamport, & Coffey, 2005)

OCCT 506: Clinical Reasoning about Occupation Form #5 activity before performing the activity in the real classroom. Second, the actual Sunday School classroom will be needed. Both of these classrooms will need to be cleared of clutter, have no windows, and have the capacity to have about 8 students sitting in chairs. Also, the classroom should not be too large because the client will be more likely to run. The only material used in the activity is goldfish. The goldfish will not be used during activity preparation, but they must be obtained during activity preparation. Because the goldfish are not actually used until activity implementation, the goldfish will be discussed in that section. The chairs that will be used need to be set up in both the preparation room and the Sunday School classroom. The chairs are off-white, metal, and heavy. A stopwatch will also need to be obtained during activity preparation. Since the stopwatch is only used during activity implementation, it will be discussed in that section. A visual reminder will need to be created. The easiest way to create it will be to use a computer and print it out in color on 8 1/2 x 11 card stock. There will be two pictures: a boy sitting quietly on a chair and a goldfish. The visual reminder will be firm but flimsy, have the pictured described with a white background, and will be light and easy to carry. Because the client has a tendency of running, the greatest safety precaution is to stay with the client at all times so that the client does not run outside onto the street. The practitioner should also be sure that the client does not run into people or things so that the client or others are not injured. The practitioner will accompany the client to the Sunday School classroom and monitor his safety. The practitioner will also use the stopwatch to monitor time and will provide a goldfish when the client has sat quietly for one minute. The practitioner will provide

Required materials

Required equipment

Safety precautions

Personnel required Activity Implementation

(Modified from Hersch, Lamport, & Coffey, 2005)

OCCT 506: Clinical Reasoning about Occupation Form #5 prompts to the client with the visual reminder as necessary. The client will sit quietly in his chair during the lesson presented by the teacher in Sunday School. When sitting quietly for a minute, the client can eat a goldfish that is provided to him by the practitioner. The teacher and classmates will play the usual role they always play when in Sunday School. The teacher will provide the lesson and the students will listen and participate as usual. If Gabe has runs or screams, they are asked to ignore the behavior unless it will cause harm to them or to Gabe. The activity will take place on Sunday at the LDS church in the usual Sunday School classroom that the client attends. The Sunday School classroom will be needed. It will need to be cleared of clutter, have no windows, and have the capacity to have about 8 students sitting in chairs. Also, the classroom should not be too large because the client will be more likely to run. Goldfish will be used during the activity as an incentive for the client to sit quietly during class time. Goldfish are edible, cheesy orange crackers that are about the size of a quarter. They make a crunching sound when being chewed and people frequently leave crumbs when eating them. The chairs are off-white, metal, and heavy. The stopwatch is black and red, light and easy to carry, has buttons to start/stop and reset, does not make any noises, does not easily break, and is hard. The visual reminder will be firm but flimsy, have the pictures of a boy sitting quietly on a chair and a goldfish, have a white background, and will be light and easy to carry. 1. The client will enter the room and sit down on a chair. Areas of Occupation o This step is under the area of ADLs, specifically in functional mobility because the client is moving from one place to another and then moving into a

Setting and location Space required

Required materials

Required equipment

Required steps and time for each step

(Modified from Hersch, Lamport, & Coffey, 2005)

OCCT 506: Clinical Reasoning about Occupation Form #5 sitting position. Client Factors o The client has the ability to maintain attention for a short period of time, remember habits and routines and things of interests, cope with emotions and regulate behaviors to a very limited degree, maintains a high level of arousal and consciousness most of the time, and has impulsive urges. The client has the ability to see and discriminate between objects, sense pain, maintains balance, and is aware of his body in space. The client has proper gait patterns, voluntary control of muscles, and functional range of motion and muscles strength in all joints of the body. The client has the ability to control bladder movements when in motion. The client has two eyes and related structures and structures related to movement. Performance Skills o The client will need to need to coordinate switching feet when walking, maintain balance when walking, and bend the torso and knees in order to sit down. The client will need to visually locate the chair and use vestibular senses to maintain balance. The client will need to control anger and frustration if he sits in a place that was not expected or desired. The client will need to plan the motor movements involved in sitting as well as judge the amount of distance that needs to be covered in order to get to the chair to sit down. The client will need to acknowledge the need for help and communicate that need to the therapist if help is desired by the client. Performance Patterns

(Modified from Hersch, Lamport, & Coffey, 2005)

OCCT 506: Clinical Reasoning about Occupation Form #5 o The client should already have established the habit of sitting down in a chair. It is not something that people usually think about. However, the client could have created a bad habit of sitting improperly or in such a way that would increase behavior outbursts. The client is also playing the role a student with the expectation that he will sit in a chair when he enters a classroom. Context & Environment o This step takes place in the Sunday School classroom on Sunday with a teacher and other sameage classmates present. There is a cultural environment in education classrooms that we expect certain behaviors from students. Sitting down when we enter into a classroom is one of them. Activity Demands o The client uses the chair and the Sunday School classroom that was discussed in the required equipment section of this document. It is expected that the client will start approaching the chair and sit down once he reaches the chair. It is expected that the client will locate the chair, walk to the chair, and then sit in the chair. All required performance skills, body functions, and body structures are listed in the client factors and performance skills sections for this step. 2. The therapist will start the stopwatch as soon as the client sits down. Areas of Occupation o This step could be placed under the area of work, specifically in job performance because the therapist is performing the activity as part of their job.

(Modified from Hersch, Lamport, & Coffey, 2005)

OCCT 506: Clinical Reasoning about Occupation Form #5 Client Factors o The therapist has the ability to maintain attention for long periods of time, remember past experiences, cope with emotions and regulate behaviors, maintains a high level of arousal and consciousness most of the time, control impulsive urges, and is highly motivated to help others. The therapist has the ability to see and discriminate between objects, sense pain, and is aware of his body in space. The therapist has voluntary control of muscles, functional range of motion, and functional muscle strength in all joints of the body. The therapist has the ability to control bladder movements when seated. The client has two eyes and related structures and structures related to movement. Performance Skills o The therapist will need to hold the stopwatch in one hand and bend his thumb to push the button to start the stopwatch. The therapist will need to position the stopwatch in his hand so that he can push the button with his thumb. The therapist will need to control frustrations if he accidently pushes the wrong button. The therapist will need to judge if he pushed the correct button and actually started the stopwatch. Performance Patterns o The act of starting a stopwatch is usually a habit that people have already developed and is not something that they think about when they do perform the task. The therapist is playing the role of a therapist in this step and is expected to be using the stopwatch as a means to monitor the behavior of the client. Context & Environment

(Modified from Hersch, Lamport, & Coffey, 2005)

OCCT 506: Clinical Reasoning about Occupation Form #5 o This step takes place in the Sunday School classroom on Sunday with the client, a teacher, and other classmates present. Activity Demands o The therapist uses the stopwatch and the Sunday School classroom that was discussed in the required equipment section of this document. It is expected that the therapist will already know how to operate the stopwatch and will not need instructions and that the therapist can hold it in one hand. It is expected that the therapist will grab the stopwatch, locate the button to push, and then push the button. All required performance skills, body functions, and body structures are listed in the client factors and performance skills sections for this step. 3. Two options are available for this step depending on what the client does. If the client sits quietly for one minute, the therapist will point to the visual reminder, praise the client for sitting quietly, and then give him one goldfish. If the client does not sit quietly, the client will point to the visual reminder, explain why client does not receive goldfish, and remind him how to obtain a goldfish. Areas of Occupation o This step is under the areas of occupation. It is placed under education, specifically formal educational participation because the client is sitting quietly in a chair in order to participate in an educational environment. It is placed under social participation, specifically peers because the client is being included in an activity with same-age peers. It can also be placed under work, specifically job performance because the therapist is taking part in tasks related to his job.

(Modified from Hersch, Lamport, & Coffey, 2005)

OCCT 506: Clinical Reasoning about Occupation Form #5 Client Factors o The client values food and especially loves goldfish. The client has the ability to maintain attention for a short period of time, remember habits and routines and things of interests, cope with emotions and regulate behaviors to a very limited degree, maintains a high level of arousal and consciousness most of the time, has impulsive urges, and is highly motivated by food. The client has the ability to see and discriminate between objects, taste different sensations, sense pain, maintains balance, to hear and discriminate words, and is aware of his body in space. The client has voluntary control of muscles, functional range of motion, and functional muscle strength in all joints of the body. The client has the ability to produce speech in an understandable way. The client has the ability to control bladder movements when seated. The client has two eyes and ears with their related structures, structures involved in voice and speech, and structures related to movement. Performance Skills o The client will need to stay in a sitting position and keep the mouth closed. The client will need to control the impulse to scream or run. The client will need to visually discriminate the pictures on the visual reminder. The client will need the ability to understand why he does or does not receive a goldfish and that his behavior affects consequences. The client will need to look at the therapist and communicate any need to get up out of his seat before getting up. The therapist will need to point to

(Modified from Hersch, Lamport, & Coffey, 2005)

OCCT 506: Clinical Reasoning about Occupation Form #5 the visual reminder and the sense to know that he is pointed to the correct pictures. The therapist will need to control frustrations and anger if the client does not sit quietly. The therapist will need to judge whether the client has sat quietly for one minute. The therapist will need to look at the client and communicate reasons why the client does or does not receive a goldfish. Performance Patterns o This step is a means of creating a habit of sitting quietly during class time with the client. The therapist is attempting to associate positive consequences with sitting quietly so that the client is more likely to do it again and again. This repeated behavior is hoped to generate a habit in the client that he will automatically perform when in the classroom. This will increase the clients ability to be successful in his role as a student who will then be able to participate in class time. Context & Environment o This step takes place in the Sunday School classroom on Sunday with a teacher and other sameage classmates present. There is a cultural environment in education classrooms that we expect certain behaviors from students. Sitting quietly in a chair while the teacher is talking is one of them. Activity Demands o The client uses the goldfish, visual reminder, and the Sunday School classroom that was discussed in the required equipment section of this document. It is expected that the client will sit quietly during class time without interrupting class by running or

(Modified from Hersch, Lamport, & Coffey, 2005)

OCCT 506: Clinical Reasoning about Occupation Form #5 screaming. All required performance skills, body functions, and body structures are listed in the client factors and performance skills sections for this step. 4. The therapist will restart the stopwatch after completing step 4. Areas of Occupation o This step could be placed under the area of work, specifically in job performance because the therapist is performing the activity as part of their job. Client Factors o The therapist has the ability to maintain attention for long periods of time, remember past experiences, cope with emotions and regulate behaviors, maintains a high level of arousal and consciousness most of the time, control impulsive urges, and is highly motivated to help others. The therapist has the ability to see and discriminate between objects, sense pain, and is aware of his body in space. The therapist has voluntary control of muscles, functional range of motion, and functional muscle strength in all joints of the body. The therapist has the ability to control bladder movements when seated. The client has two eyes and related structures and structures related to movement. Performance Skills o The therapist will need to hold the stopwatch in one hand and bend his thumb to push the button to start the stopwatch. The therapist will need to position the stopwatch in his hand so that he can push the button with his thumb. The therapist will need to control frustrations if he accidently pushes the wrong button. The therapist will need to judge if he pushed the correct button and actually restarted the

(Modified from Hersch, Lamport, & Coffey, 2005)

OCCT 506: Clinical Reasoning about Occupation Form #5 stopwatch. Performance Patterns o The act of resetting a stopwatch is usually a habit that people have already developed and is not something that they think about when they do perform the task. The therapist is playing the role of a therapist in this step and is expected to be using the stopwatch as a means to monitor the behavior of the client. Context & Environment o This step takes place in the Sunday School classroom on Sunday with the client, a teacher, and other classmates present. Activity Demands o The therapist uses the stopwatch and the Sunday School classroom that was discussed in the required equipment section of this document. It is expected that the therapist will already know how to operate the stopwatch and will not need instructions and that the therapist can hold it in one hand. It is expected that the therapist will grab the stopwatch, locate the button to push, and then push the button. All required performance skills, body functions, and body structures are listed in the client factors and performance skills sections for this step. 5. The therapist and client will repeat steps 4 and 5 for a period of 10 minutes. Since this step is repeating steps 4 and 5, the same things listed under these steps also apply here. Because the client has a tendency of running, the greatest safety precaution is to stay with the client at all times so that the client does not run outside onto the street. The practitioner should also be

Safety precautions

(Modified from Hersch, Lamport, & Coffey, 2005)

OCCT 506: Clinical Reasoning about Occupation Form #5 sure that the client does not run into people or things so that the client or others are not injured. Describe how the activity overall fits Areas of Occupation: The activity falls under two areas of into the domain(s) of occupational occupation: education and social. Sunday School class is a type of therapy in detail. Consider: formal educational activity. Gabe is learning about his religion. The activity is also social because Gabe is learning how to behavior Areas of Occupation in a socially appropriate way with his peers. During class, society Client Factors expects us to sit quietly and listen to the teacher and then raise our Performance Skills hand to answer questions. When there is an activity during class, it Performance Patterns is expected that students follow the rules the teacher explains for Context & Environment the activity. The activity helps Gabe learn to follow the social rules Activity Demands of sitting quietly in his chair, which is part of these social rules. Client Factors: The client factors for the activity were basically the same across each step the client was to complete. The client values food and especially loves goldfish. The client has the ability to maintain attention for a short period of time, remember habits and routines and things of interests, cope with emotions and regulate behaviors to a very limited degree, maintains a high level of arousal and consciousness most of the time, has impulsive urges, and is highly motivated by food. The client has the ability to see and discriminate between objects, taste different sensations, sense pain, maintains balance, to hear and discriminate words, and is aware of his body in space. The client has voluntary control of muscles, functional range of motion, and functional muscle strength in all joints of the body. The client has the ability to produce speech in an understandable way. The client has the ability to control bladder movements when seated. The client has two eyes and ears with their related structures, structures involved in voice and speech, and structures related to movement. Performance Skills: The most important of these skills in this

Domain

(Modified from Hersch, Lamport, & Coffey, 2005)

OCCT 506: Clinical Reasoning about Occupation Form #5 activity is the ability to control behavioral impulses to run or scream. The client also needs the ability to visually discriminate between the pictures in the visual reminder. The client will need the ability to understand why he does or does not receive a goldfish and that his behavior affects consequences. The client will need to look at the therapist and communicate any need to get up out of his seat before getting up. Performance Patterns: The goal of the activity is to establish in the client the habit of sitting quietly in Sunday School class in order to increase his ability to place the role of a student. The therapist uses the goldfish as a means of teaching the client that positive consequences are associated with sitting quietly. Therefore, the client is more likely to continue sitting quietly in class. Repeatedly sitting quietly in class with then become habit for the client and the goldfish will eventually not be needed in therapy. Context & Environment: The main contexts and environments are the physical environment, the social environment, and the cultural environment. The physical environment is the Sunday School classroom. The social environment is the classroom teacher and other same-age classmates. The cultural environment is educational in that we expect certain behaviors from students. Sitting quietly in a chair while the teacher is talking is one of them. Activity Demands: The client uses the goldfish, visual reminder, and the Sunday School classroom that was discussed in the required equipment section of this document. It is expected that the client will sit quietly during class time without interrupting class by running or screaming. All required performance skills, body functions, and body structures are listed in the client factors and performance skills sections.

(Modified from Hersch, Lamport, & Coffey, 2005)

OCCT 506: Clinical Reasoning about Occupation Form #5 Discuss how you have utilized the occupational profile, activity preparation, and activity implementation to achieve occupational therapy outcomes. The occupational profile was used to get to know and understand the client as a person. It allowed me to see the client holistically and understand the strengths and weaknesses that he had. I was also able to see that the parents wanted to work on his behavior problems during Sunday School class. I incorporated that occupation with interests of the client into an activity that I reasoned would be beneficial to the client. The use of goldfish, an incentive for the client, during class time would help teach him to sit quietly during class instead of running and screaming. I knew that this would require some preparation before actually implementing the activity. For instance, the client, his teacher, and his classmates would need some education about the activity so they could be preparation for its implementation. I knew from the occupational profile that the client has autism. I know that visual reminders with pictures can be helpful to those with autism, so I incorporated that into the activity preparation and implementation. I also implemented an ABA-type of therapy because it has been known to work well with those with autism. That is why I decided to use the goldfish to help teach the client during the actual occupation of attending Sunday School. The goldfish should be a motivator for him to sit quietly like his peers. All of the reasoning derived from the occupational profile and the creation of the activity are hoped to achieve the outcome of teaching the client to sit quietly during Sunday School class. This would fall under the category of establish/restore because the client is learning a new skill. The parents would also improve their quality of life because they will have less stress about their son during Sunday School at church. Gabe seemed excited to see the therapist since last Sunday. He seemed willing to participate in therapy. Parents report that Gabe is tired today and may have more outbursts than usual. Parents also report that his screaming behaviors have been decreasing in school

Process

Subjective SOAP Note

(Modified from Hersch, Lamport, & Coffey, 2005)

OCCT 506: Clinical Reasoning about Occupation Form #5 and hope that this will transfer to Sunday School as well. When educating Gabe on the activity, he seemed to understand the activity and was eager to participate. When practicing sitting in the preparation room, Gabe sat quietly for 2 minutes. After entering the classroom, Gabe sat in a chair in the back of the classroom. He sat quietly in the chair for 5 minutes, receiving a goldfish after each minute. After those first 5 minutes, he began rocking in his seat and then screamed. The therapist prompted him to sit quietly again. He sat quietly again for 2 minutes, again receiving a goldfish after each minute, then screamed again. Gabe received another prompt from the therapist then sat quietly again for 3 minutes. Gabe is showing improvement in therapy. He screamed only twice during the session as opposed to four times last Sunday. Also, he never attempted to run out of the room. This shows great potential for Gabe to improve since running has been eliminated and screaming has been decreased. It is also impressive that he showed improvement even when his parents reported that he was tired and more prone to behavioral outbursts. However, he has not yet reached his goal of sitting quietly for 10 minutes without running or screaming. The plan is to continue with the way therapy is going, but to increase the amount of time for receiving a goldfish from 1 minute to 1 minutes.

Objective

Assessment

Plan

(Modified from Hersch, Lamport, & Coffey, 2005)

OCCT 506: Clinical Reasoning about Occupation Form #5 James, Excellent job with this assignment. Throughout the semester, you have demonstrated the ability to synthesize information from all of your coursework into higher-level application assignments. Keep up the good work! Prof. A. Grade: 39/40

(Modified from Hersch, Lamport, & Coffey, 2005)