Artifact 7 Pediatric Case Study

OCTH 6140 - Integrative Case Study #3 Name: ____Tambra Rasmussen__________________________
This assignment involves synthesizing or integrating the information from OTCH 6120 (Theory), OCTH
6140 (Skills) and OCTH 6160 (Evaluation) on the module we completed on school-aged children. The
format for this case study replicates the occupational therapy process from referral through evaluation
and planning intervention.
You are to complete all the questions in the order that they appear. As in the therapy process, you will
gain more information as you go through the case. DO NOT change your answers to earlier questions as
you gain more information. It is important for you to reflect on your thinking processes and to identify
information you need and want to obtain as you learn more about the child and his family.
It is recommended that you use the OTPF as a resource, and you’re also allowed to use your notes,
textbooks, or the internet to help you to answer the questions. References must be given on designated
questions.
Case Study
1. Referral
Sasha is a 10-year-old girl who attends a regular 5th grade classroom. Her teacher referred her for a
comprehensive evaluation due to concerns about Sasha’s behavior in the classroom, her difficulty
completing assignments, poor handwriting, and her aggressive behavior on the playground. You are
the occupational therapist who will do part of Sasha’s comprehensive evaluation.
a) What are two possible diagnoses that Sasha may have? (Include diagnostic information for the
diagnoses you select and relate it to information found in the referral. Provide references.)
1. Attention Deficit Hyperactivity Disorder (ADHD): According to understood.org, a

resource for ADHD, children Sasha’s age with ADHD may produce messy school work,
may not finish activities such as homework or chores, and may be impulsive and do
things without considering the consequences which may explain her aggressive behavior
on the playground. Kids with ADHD also may play roughly which may be misconstrued
as aggressive behavior. All three of the concerns Sasha’s teacher noted are also
symptoms of ADHD in children Sasha’s age according to the resource I found on-line
(understood.org). According to the DSM V, to be diagnosed with ADHD, there must be a
“persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with
functioning or development.” The DSM V provides a list of 9 symptoms of inattention,
and to meet the criteria, the child must have 6 or more. The following criteria of
inattention may pertain directly to Sasha:
• “Often fails to give close attention to details or makes careless mistakes in
schoolwork.”
• “Often has difficulty sustaining attention in tasks or play activities.”
• “Often does not seem to listen when spoken directly to.”
• “Often does not follow through on instructions and fails to finish schoolwork,
chores or duties in the workplace.”
• “Often has difficulty organizing tasks and activities.”
• “Often avoids, dislikes, or is reluctant to engage in tasks that require sustained
mental effort.”
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• “Often loses things necessary for tasks or activities.”

• “Is often easily distracted by extraneous stimuli.”
• “Is often forgetful in daily activities.”
In addition to inattention, to be diagnosed with ADHD per the DSM V, the child must also
demonstrate at least six or more of the following symptoms of hyperactivity and impulsivity.
The symptoms include:
 ”Often fidgets with or taps hands or feet or squirms in seat.”
 “Often leaves seat in situations when remaining in seat is expected.”
 “Often runs about or climbs in situations where it is inappropriate.”
 “Is often on the go, acting as if driven by a motor.”
 “Often talks excessively.”
 “Often blurts out an answer before a question has been completed.”
 “Often has difficulty waiting his or her turn.”
 “Often interrupts or intrudes on others.”
2. Autism: According to the Autism Speaks website, a core symptom of autism is social
deficits which may account for Sasha’s aggressive playground behavior. Language
impairment is another core symptom of autism which may be why she has a difficult
time with handwriting which is a form of expressive language. Associated neurological
issues experienced by some people with autism include attention problems, ADHD, and
anxiety, all of which may account for Sasha’s difficulties with finishing assignments.
According to the DSM V, to be diagnosed with Autism, a child must show “Persistent
deficits in social communication and social interaction across multiple contexts as
manifested by the following, currently or by history.”
• “Deficits in social-emotional reciprocity.”
• “Deficits in nonverbal communicative behaviors used for social interactions.”
• “Deficits in developing, maintaining, and understanding relationships.”
In addition to deficits in social communication/interaction, a child must also show
“restricted, repetitive patterns of behavior, interests, or activities as manifested by at
least two of the following:”
• ”Stereotyped or repetitive motor movements, use of objects or speech.”
• “Insistence on sameness, inflexible adherence to routines, or ritualized
patterns.”
• ”Highly restricted, fixated interests that are abnormal in intensity and focus.”
• “Hyper/hypo reactivity to sensory input or unusual interest in sensory aspects of
the environment.”
b) Pick one of these diagnoses. Name the diagnosis you selected and identify four occupations
from Table 1 of OTPF (ex: Activities of daily living-dressing) that could be affected if the child has
this diagnosis.
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Diagnosis: __ Attention Deficit Hyperactivity Disorder ____________________________
List four specific occupations that may be affected for Sasha:
1. __Participation in formal education______________________

With ADHD, an occupation that may be affected includes participation in formal education.
According to understood.org, children Sasha’s age with ADHD may have a variety of symptoms
that will impact their ability to function in a school setting including the classroom, lunchroom,
playground, and socially. The following are symptoms that may make participation at school
difficult.
• may have trouble initiating tasks
• Be restless
• Fidget
• Forget what they just heard
• Rush through assignments and make careless mistakes
• Produce messy work
• Lose focus
• Work below their potential
• Have trouble remembering steps in a task
• They may not finish activities such as homework or chores
• May have trouble taking turns in conversation and worry they will forget what to say if they do
not speak immediately after they have a thought
• Act on impulse without considering consequences
• May work slowly, or may have a difficult time finishing tasks within a reasonable timeline.
• Additionally, according to the DSM V, children with ADHD may have speech delays, gross motor
delays, fine motor delays, and/or sensory processing disorder.
2. __Social Participation_________________________________
Another occupation that may be impacted by ADHD is social participation. Symptoms of ADHD
such as impulsive behavior, and difficulty taking turns in conversation may make it difficult to
interact appropriately with other people including friends and family.
3. _ Sleep____________________________________________
Sleep may be affected by ADHD. Children with ADHD often have a difficult time settling down at
night to fall asleep and a difficult time staying asleep.
4. __IADL’s such as shopping, cooking and cleaning__________

Occupations such as cooking, shopping, and cleaning may also be affected by ADHD. Symptoms
such as forgetting things, difficulty with sequencing, loss of focus and working too slowly may
make it difficult to participate in age appropriate IADL’s.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.). Arlington, VA: Author.
Brown, T. E. (n.d.). Retrieved November 07, 2017. Signs of ADHD at different ages
from https://www.understood.org/en/learning-attention-issues/signs-symptoms
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Diagnostic and Statistical Manual of Mental Disorders (5th ed: DSM-5; American Psychiatric Association,
2013).
I also took a closer look at autism to get a better idea of impact on occupation because I am
really not sure what condition the client may have at this point.
With Autism, occupations that may be impacted include ADL’s which may be impacted due to
sensory processing issues that may make it difficult to participate in bathing, toileting, dressing, feeding
and grooming.
Meal preparation which is an IADL may be difficult for children with autism if there are sensory
concerns with the way foods smell, look, or taste.
Education may be negatively impacted by autism. Speech and language difficulties that are
often associated with autism would make communication in a school environment difficult.
Additionally, changes in routine, perseverant interests, fidgeting, and an inability to recognize safety
issues would all impact participation in school.
Social participation is often difficult for children with autism. They may avoid eye contact and
physical contact which may be misconstrued by typical peers as standoffish or disinterested. Frustration
due to delayed speech or being non-verbal would also affect social participation. Additionally, children
with autism may be excluded from social activities more frequently than their neuro-typical peers
(Taheri 2016.)
Taheri, A., Perry, A., & Minnes, P. (2016). Examining the social participation of children and
Adolescents with intellectual disabilities and autism spectrum disorder in relation to
Peers. Journal of Intellectual Disability Research, 60 (5), 435-443
Symptoms. (2013). Retrieved November, 7, 2017 from

https://www.autismspeaks.org/what-autism/symptoms
c) Based on childhood development, what performance tasks would you typically expect a child of
this age to be doing in each of the following areas of occupation (be specific)? Not all areas may
apply.
Area of Occupation Developmental Expectation
Activities of Daily Living -Bathing/showering independently, at this age, the

child is able to turn on and adjust water temperature
and independently bathe the entire body including
washing their hair.
-Toileting independently, at this age, a child will be
able to independently pull down their pants, wipe
themselves, and get redressed after using the toilet.
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-Dressing independently, at this age, a child is able to

fasten buttons, snaps, Velcro, zippers, hooks and
eyes, and any other common fasteners
independently. They know the difference between
the front and back of a garment, and know what shoe
goes on which foot. If they are unsure, they are able
to identify the tag in a garment, and decipher front
from back.
-Swallowing/eating independently, at this age, a child
should be able to keep their food in their mouth with
their lips closed.
-Feeding independently, at this age, a child should be
able to cut their own food into manageable pieces,
and use the culturally expected utensils to eat a meal.
-Hygiene and grooming tasks would include
washing/combing and doing basic styling on hair, nail
care including trimming nails, using deodorant, tooth
care including brushing and flossing.
Instrumental Activities of Daily Living IADL’s that a typically developing 10-year-old may
participate in include:
- Pet care, they can give pets food and water and
clean up after them.
-Some basic child care, for example, playing with a
younger sibling so mom can make dinner.
-Communication Management, at this age, they may
be learning to use a day planner at school, use a
computer/tablet, and may have a cell phone to
communicate with family and friends.
-Community mobility-able to walk/ride a bicycle in
their immediate neighborhood, may walk to/from
school.
-Financial Management-may receive an allowance or
earn money for doing chores. Will be able to decide
what they want to spend their money on, save for a
special purchase, or start saving for a long-term goal.
-Health Management- may be able to help with
management of medications, for example, tell
parents when they need their asthma inhaler. At this
age, they also understand basic nutrition and fitness,
and may participate in fitness activities or be involved
in making food decisions based on their personal
needs. Children with medical diagnoses will be able
to communicate symptoms to other people.
-Home Establishment and Management-able to use
the washer and dryer to care for their own clothing.
They will be able to care for their own toys and
sporting equipment.
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-Meal Prep/Cleanup, can make a basic cold meal, and

some hot meals with assistance.
Religious and Spiritual activities, children this age may
attend church with their family or friends. They may
choose their level of participation.
-Safety and emergency maintenance-have a basic
understanding of a variety of situations, for example,
they know the family’s plan if the fire alarm goes off,
they know what situations warrant a call to 911, they
can gauge when a situation appears unsafe, and
know to either leave the situation or get an adult’s
help.
-Shopping, can decide what they would like to buy,
with help, go to the store, find the item in the store,
then make a transaction with a sales clerk to buy the
object. At this age, they would be using cash for
transactions.
Additionally, per our Case-Smith text book, page 466,

children this age can set up and clear the table before
and after meals, arrange for rides to places, ride
public transportation with supervision, help put away
groceries, help with recycling, can answer the phone
and take messages, may have a savings account, with
help can plan and implement get-togethers with
friends, they may start to independently follow
routines.
Rest and Sleep -Rest, recognize when they are tired and need to
relax. Can identify ways to relax.
-Sleep preparation, should participate in a routine to
get ready for bed. For example, putting on pajamas,
brushing and flossing teeth, reading a story to
themselves or to their parents, then being tucked in
for the night by their parents.
-Sleep participation, may recognize that they need a
routine to wind down to prepare for sleep.
Education -Expected to attend and participate in formal
education.
-May take classes outside of school in areas of
interest such as taking dance classes or music lessons.
Work Aside from possibly doing chores for an allowance,
work is not applicable to this population.
Play -Play exploration, should be able to participate in
games with rules, constructive play and symbolic
play.
-Play participation, has a good balance between play
and other activities such as education. Takes care of
toys by keeping them clean and putting them away.
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Leisure -Can identify and participate in a variety of leisure

activities. Knows how to obtain the supplies
necessary to participate.
Social Participation - interact appropriately with a variety of people in the
school, neighborhood, at events, and at church.
Know how to interact with their family in their
specific role as a child/sibling/niece/grandchild etc.
Know how to initiate conversation and play with
similarly aged peers. Can initiate appropriate
conversation with adults such as parents and
teachers.
2. Preparation for Evaluation
You review the referral and learn the following: Sasha received occupational therapy in kindergarten but
met academic expectations and did not qualify for further specialized educational services. She began to
struggle in 3nd and 4th grades but successfully met academic expectations. Sasha had difficulty with
handwriting, difficulty following directions, staying on task, completing tasks, and participating with
peers during recess. She was easily upset by unfamiliar environments, people standing too close to her,
and with changes in schedule. The school psychologist observed her and made recommendations to her
teacher for modifying instructions and giving her more time to complete tasks. With these
accommodations, Sasha completed the earlier grades but continued to require assistance to learn, to
complete tasks, to complete her work in a timely manner, to remember her belongings and her
homework, and to engage in recreational and gym activities. She was evaluated at the end of 4th grade
and was placed on an Individualized Education Plan (IEP), which determined that she would receive
special education services to support her academic success.
Now, in 5th grade, Sasha continues to exhibit problems in the classroom and during recess despite
adaptations. She is in danger of being held back because she does not complete assignments and is not
meeting academic expectations. The special education team decided to refer Sasha for a comprehensive
occupational therapy evaluation. Sasha’s mother agreed to the evaluation and expressed concerns
about Sasha’s ongoing difficulties with handwriting, completing homework, getting along with peers,
and poor coping skills.
a) From the information above, identify three associated risk factors and/or deficits associated with
listed diagnoses that may influence Sasha’s development (Cite information source
Risk Factor or Deficit Discuss the barriers to development/performance that may present
due to this risk factor or deficit (cite information sources)
1. Attention, or in the According to the DSM V, for a child to be diagnosed with ADHD they
case of ADHD, must have a minimum of six of the following nine symptoms
inattention regarding inattention, all of which may have a significant impact on
development as well as academic performance.
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“Often fails to give close attention to details or makes careless

mistakes in schoolwork.” A lack of details/careless mistakes may
lead to bad grades.
“Often has difficulty sustaining attention in tasks or play activities.”
Being unable to sustain attention will make it difficult for Sasha to sit
still and listen to lectures in the classroom.
“Often does not seem to listen when spoken directly to.” If she does
not appear to pay attention, this may be frustrating to teachers,
parents, and other people who may misconstrue this for disinterest.
“Often does not follow through on instructions and fails to finish
schoolwork, chores or duties in the workplace.” By not following
through on school work, Sasha is at risk of failing classes and being
held back. At home, she may not be meeting household
expectations regarding chores.
“Often has difficulty organizing tasks and activities.” By not being
organized, Sasha may have a harder time than other students to find
the materials needed for assignments, or she might not be able to
keep track of due dates.
“Often avoids, dislikes, or is reluctant to engage in tasks that require
sustained mental effort.” In school, there are expectations of
required work. Sasha may not be meeting these expectations if she
is not engaging in tasks that require sustained mental effort.
“Often loses things necessary for tasks or activities.” It is difficult to
perform well in school if you do not have all of the materials you
need to perform the tasks required of you.
“Is often easily distracted by extraneous stimuli.” By being
distracted, Sasha may not pay attention to what the teacher is
saying and miss important information.
“Is often forgetful in daily activities.” Being forgetful can make it
difficult to turn in assignments on time, or remember the steps
necessary to complete an assignment.
Due to inattention, Sasha may make mistakes or miss details in

schoolwork. Inattention may also manifest as an inability to pay
attention while listening to a lecture, reading a book, or having a
conversation. She may not follow through on assignments or
chores. Additionally, she may have a difficult time with organizing
materials, or sequencing events while completing an assignment.
She may lose items necessary for tasks such as school supplies.
Attention Deficit Hyperactivity Disorder. (n.d.) Retrieved November

13, 2017 from
https://www.nimh.nih.gov/health/topics/attention-deficit-
hyperactivity-disorder-adhd/index.shtml
DSM-5 Diagnostic Criteria.
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2. Education According to Loe and Feldman (2007), kids with ADHD may have
poor grades, poor scores on standardized tests, and are at risk of
repeating a grade. ADHD is associated with the need for more
school-based services, a higher rate of expulsion, and lower
graduation rates. Having ADHD also impact’s a child’s chances of
going to college. Sasha is already showing some of these
educational deficits. She has poor grades, and is at risk of repeating
a grade. She is also at a point where she needs school based OT
services to help keep her on track to stay caught up with her class.
Loe, I.M., & Fledman, H.M. (2007). Educational and academic

outcomes of children with ADHD. Journal Of Pediatric
Psychology, 32(6), 643-654. Doi:10.1093/jpepsy/js1054
3. Social Participation Children with ADHD often do not recognize how their behavior
effects other people. Behaviors such as interrupting other people,
acting impulsively, and being intense may make it difficult for them
to make and keep friends. They may have a difficult time following
conversations or go off topic when talking to others. Sometimes
children with ADHD have a hard time with self-control and may have
reactions to situations that are intense and not age appropriate.
Sasha shows difficulty with self-control when she hits peers who
invade her personal space.
Morin, A., & Cunningham, B. (n.d.) How ADHD can affect your child’s
social life. Retrieved November, 14, 207, from
www.understood.org/en/learning-attention-issues/child-
learning- disabilities/add-adhd/5-ways-adhd-can-affect-your-
childs-social-life
According to Hoza et al. (2005) “more than half of children with

ADHD are widely disliked by their peers.” She also goes on to note
that more than half of children with ADHD do not have reciprocated
friendships, and when they do make friends, the friendship is more
likely to end than those of typical peers. This lack of friendship may
be due to impulsivity, non-stop activity, and aggressive behavior in
children with hyperactive ADHD. Children with inattentive ADHD
may appear disinterested and withdrawn. They also may lack
awareness of other people’s feelings. Sasha has a history of getting
into fights with other children. This indicates that she may not be
well liked by some of the kids in her neighborhood or that she goes
to school with. If she has a reputation of aggressive behavior, it may
be harder for her to make friends, and have age-appropriate social
interactions.
Hoza, B., Mrug, S., Gerdes, A. C., Bukowski, W. M., Kraemer, H. S.,
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Wigal, T., & Arnold, L. E. (2005). What aspects of peer

relationships are impaired in children with Attention-
Deficit/Hyperactivity Disorder? Journal of Consulting and
Clinical Psychology, 73, 411-423.
Per Sourciss, Mainsonneuve, and Normand (2015), children with

ADHD are also more likely to break rules or boss other kids around
when playing. They also were more likely to make self-serving
suggestions. All of which may impact social participation. If Sasha is
breaking rules while playing with other kids, or being bossy, it may
limit her opportunities for engaging in social activities such as play
on the playground, eating lunch with friends, playing with neighbor
children, or going to parties.
Sourciss, M. M., Maisonneuve, M., & Normand, S. (Winter 2015).

Friendship problems in children with ADHD: What do we know
and what can we do? Perspectives on Language and Literacy,
29-34.
b) Pick two of the risk factors and/or deficits you identified above. Next to each risk factor or deficit
identify:
a. How it may affect Sasha’s occupational performance at home
b. How it may the affect Sasha’s occupational performance at school
#1__Attention____________________________________________
Impact on Sasha’s occupational performance at home:

Sasha’s difficulties with attending to tasks at hand may cause problems with completing ADL’s,
and IADL’s at home. Additionally, interactions with her parents and other family members may be
negatively impacted. Inattention to instructions to do her chores may cause Sasha’s mother to become
angry, or by not paying attention to conversation, Sasha may appear to be disinterested. Completing
ADL’s such as bathing and feeding need to be done in a timely manner. Due to inattention, Sasha may
complete them too fast, too slowly, or miss important steps, for example, when bathing, she may forget
to use soap, or not wash her hair. A child her age should be able to perform all of the steps of bathing
independently. Performance of IADL’s may be impacted as well. Difficulty with organizing materials,
with sequencing, and lack of follow through may make it difficult for Sasha to safely and efficiently do
things such as prepare a meal, or do chores such as emptying the dishwasher. A lack of attention when
receiving directions from her parents may cause them frustration and anger. Other family members and
caregivers may feel this way as well.
Impact of occupational performance problems on school experience:

Inattention may cause Sasha difficulties with following instructions in the classroom. She may
fall behind her classmates because she is unable to pay attention to verbal or written instructions. This
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may also be a concern at recess when she is playing games with her peers. When completing
assignments, Sasha may either rush through them, not do them at all, or not finish them. All of these
factors can lead to poor grades, and the possibility of being held back. Difficulty with organizing her
school supplies may cause her further complications at school. Sasha’s teacher may consider her to be a
difficult student which may also impact her school experience. If her teacher is frustrated by her
actions, Sasha may be disciplined more frequently which may take a toll on her self-esteem as well as
make her less willing to cooperate in the future.
#2 _Social Participation________________________________________
Impact on Sasha’s occupational performance at home:

Sasha may be unaware of when her behavior is affecting other people such as her mother, or
other family members she may live with. She may do things that are annoying or unacceptable, and not
even realize it. This may cause her parents and other family members to become frustrated, angry, or
embarrassed. An awareness that she does not have friends like other children do may cause Sasha to
feel sad, angry or hurt. Her parents and family members will be responsible for coaching her through
these tough situations which may not be something they are good at or prepared for. When asked to
participate in activities as a family, such as a game night, Sasha may not pay attention to directions, and
when the game does not go the way she wants it to, she may lash out which would make an activity that
was supposed to be fun for the family frustrating.
Impact of occupational performance problems on school experience:

Impulsive behaviors, combined with inattention may make it difficult for Sasha to make and
keep friends. At school, this may be extra difficult because she will want to fit in, and do what the other
children do. Her inability to follow directions may prevent children from picking her to play on their
team at recess or in P.E. class. Other students may not want to work with her on group projects because
they would fear that she would not do her share of the work, or that she would do her portion poorly.
Sasha may also be bossy and break rules which make it difficult for other people to want to be around
her. If she were to ever run for Student Counsel or other organizations that you need to be voted into,
her chances of making it would be lower than those of her typically developing peers. Due to concerns
with social participation, Sasha may be at risk for not developing normally because she will not have the
same opportunities to participate that other children have.
c) Domain Analysis: Based on what you know, highlight domains that you think need further
investigation during your initial evaluation to see how they might be impacting the child’s
occupational performance and their school and family life?
Occupations Client Factors Performance Performance Context &

Skills Patterns Environment
ADLs Values Motor Skills Habits
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IADLs Beliefs Cultural

Spirituality Personal
Rest & Sleep Routines
Education Body Functions Process Skills Physical

Social
Work Rituals
Play
Leisure Body Social Roles Temporal

Structures Interaction Virtual
Social Skills
Participation
I could argue that every area should be highlighted. I chose the areas that I believe pose the
greatest concern for Sasha based on what I know about her. ADL’s could be a concern if they are not
being completed in a timely and effective manner. For example, if Sasha is not bathing well, she may be
at risk for infections, or teasing from peers if she looks/smells dirty. IADL’s are likely being impacted by
her difficulty with following directions, but it is unknown exactly why this is a problem for her, and what
accommodations are already being made for her. If Sasha has ADHD, her sleep may be impacted. She
may have a difficult time falling asleep and staying asleep. This is something I want to know more
about. Poor sleep hygiene may affect all aspects of her life. Sasha is noted to have trouble getting along
with peers. This may be affecting both her play and social participation. She also does not like
unfamiliar environments which may have an impact on social participation. I want to get a better
understanding of her values, beliefs and spirituality to see how they may intertwine with her school
experience and expectations in the home. I want to take a closer look at attention, memory, executive
function, emotional regulation, sequencing, and judgement to see if there is a correlation between her
difficulties and these mental functions. I want to see her interact with her peers, and see how she fulfills
her roles as a student, daughter, and friend. I would also like to see how she views herself within her
personal context as well as take a look at supports and barriers in her physical and social environments.
3. Evaluation Plan
a) Practice Models Guiding your Evaluation & Assessment
Based on what you know so far (age, diagnosis, concerns, setting, risk factors, etc.) and all the factors
considered above:
• Choose an organizing practice model (i.e. PEO, MOHO) that will help guide you in the overall
evaluation process. Be specific and describe how this model would direct your evaluation
process.
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• Choose at least 2 (two) complementary OT models that will help guide you in the overall
evaluation process. Be specific and describe how this model would direct your evaluation
process. List only those most pertinent.
• REMEMBER you want to choose a model that provides a foundation for a COMPREHENSIVE
evaluation plan.
Practice Models Brief description of the practice model How this practice model would direct
your evaluation (i.e. what would you
be looking for based on this model)
Organizing: MOHO looks at motivation for We can use MOHO to determine what
Model of Human occupation, how to maintain positive motivates Sasha in order to help her
Occupation involvement in life roles, skilled improve her occupational
(MOHO) performance of life tasks, the influence performance. MOHO can be used to
of the physical and social help Sasha find ways to have positive
environments, and occupational involvement in her life roles, especially
adaptation. Additionally, MOHO looks those of friend, student, daughter, and
at volition, habituation, performance peer. Additionally, MOHO can be used
capacity, environment, occupational to improve skilled performance and to
identity, and occupational find ways to make the physical and
competence. social environments more conducive to
enabling Sasha’s occupational
performance. Overall, MOHO will help
Sasha create an occupational identity
and perform competently within this
identity in a variety of settings and
situations.
Complementary The overall outcome of the sensory Sensory integration looks at how a
#1: Sensory integration model is successful person is able to modulate,
Integration participation in life activities at home, discriminate and integrate sensory
school, in the community and in other information from the environment. It
environments. also looks at how a person may
regulate their arousal levels, and
praxis. Sasha appears to have some
difficulty with certain sensory input.
For example, she does not like it when
people stand too close to her. This
model can be used to determine if
there is sensory integration
dysfunction, and how it may be
impacting Sasha’s ability to participate
at school.
Complementary The aim of this model is to help youth With this model, we can identify
#2: Social form more organized patterns of Sasha’s behavior deficits to facilitate
Participation behavior that allow better social participation and better
participation in school and family communication. The Social
environments. Participation Model can be utilized to
see what Sasha’s patterns of behavior
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are regarding social participation. This

model allows us to look at
temperament, self-regulation, habits of
social interaction, social routines,
social competence, and functional peer
interactions to determine what Sasha’s
strengths and barriers are regarding
social participation.
Complementary The aim of the Kawa Model is to The Kawa Model can be used to help
#3: Kawa Model enhance life flow by enhancing get a better idea of what Sasha, her
harmony between all elements of a teacher, and her mother perceive to be
person’s life and contexts. It uses a her supports and barriers. I feel that
river to represent life flow, and objects the visual representation of the river
like rocks or logs in the river may used by the KAWA model may be a fun
represent barriers. and easy way for a child Sasha’s age to
identify supports and barriers, and it
will provide an easily interpreted
picture of what we are going to work
on in OT that she can reference.
b) Obtaining Occupational Profile
List the three most important questions you would ask Sasha’s teacher at her evaluation. State the
questions in the words you would use with her teacher.
1. In the classroom, what do you feel is the biggest barrier to Sasha’s success as a student?
2. What does Sasha do well; for example, does she excel at anything academically? Is there an
activity she is really good at?
3. Have the adaptations made at the recommendation of the psychologist had an impact on
Sasha’s performance at school, and if so, how?
List 4 occupational performance tasks that you would want to observe Sasha participating in during the
evaluation (consider what a child this age should be doing).
1. Play with peers -how does she interact, what do her social skills look like, is she participating
fully in an age appropriate manner? To facilitate this, I may have her play a playground game
such as hopscotch with some other students to see how she interacts.
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2. Handwriting – because this is a school evaluation, and she is having a hard time with this skill
which may be impacting her ability to do her school work. At this age, changing her writing
ability may not be practical since her habits are likely ingrained. It might be better for her to
type or use voice to text if handwriting is a barrier to getting her work done in a timely/effective
manner. To see how Sasha completes a handwriting task, I will have her copy a sentence of my
choosing, and write a paragraph about a subject of her choice.
3. Classroom behavior/set up- what is she doing during class? Is she sitting in her seat, roaming
around, fidgeting, paying attention? Is she disrupting class? Is she in a seat that faces forward
and makes it easy to see what the teacher is doing/chalk board? Is she distracted by anything in
her immediate environment? I will attempt to make this observation unknown to Sasha so that
her behavior will be as natural as possible.
4. How does Sasha organize herself? What does her desk and backpack look like? Are school
supplies easily found and used? Does she have a planner or other system in place to keep track
or assignments?
c) Assessments/Tools
Identify 1 or 2 appropriate assessment tools you would use to evaluate Sasha during this initial one-hour
session, other than your interview for your occupational profile and observation of performance skills
(these are listed for you in the table). Be sure to consider the practice setting and remember that asking
questions for the occupational profile, observation and analysis of occupational performance, and
assessments should take no longer than one hour collectively. Next to each assessment, briefly describe
information you hope to obtain using this method. Also identify the practice model that guided your
choice of this tool with a brief rationale. You may schedule a return visit to collect additional
information.
Also, in the Observation row, list the information you would hope to obtain, practice model and
rationale. In the Interview role, identify if your interview would be informal vs structured/standardized
(such as the COPM), what information you would hope to obtain, the practice model, and rationale for
your choice.
Strategy/Assessment Information you would hope to Practice Model & Rationale

Tool obtain
Observation I would like to see how Sasha MOHO-looks at volition, habituation,
interacts with her peers and performance capacity, environment,
teacher. How does she carry on a occupational identity, and occupational
conversation, is she paying competence. For Sasha, all of these are
attention in class, is her behavior impacting her ability to fully participate
appropriate for the setting? Is at school both academically and
she distracted by anything in the socially.
classroom? I want to know how
she organizes her desk,
schoolwork, and backpack. I want
15
to observe her classroom

behavior-is she quiet, loud,
obnoxious, or appropriate? Does
she sit still, fidget, move around
the room? Where does she sit in
the room?
Interview- From the interview, I would like MOHO – with MOHO, we can get a
Type/Tool: Informal if to get a better idea of what is better idea of Sasha’s desires, and what
it is just Sasha and I. If important to Sasha, her parents, will make her want to participate more
her mother is present, and her teacher. I would also like fully. We can also get a better idea
I would like to to get to know her better. Find about her habits, environments, and
administer the COPM out what is important to her, competency within her expected life
to determine her what she feels her strengths are, roles.
perspective on what and what she feels is difficult for
needs to be addressed her. I would like to find what she Social Participation-through
and prioritized. likes about school and dislikes interviewing, we can find out more
about school, and see if she has about Sasha’s social participation.
any ideas of what might help her What it looks like now, and what she,
perform better academically and her parents, and her teacher wants it to
socially. I would also like to see if be like in the future.
she identifies any friends, and if
so, what does her relationship Kawa Model-as part of the informal
with them look like? interview, while speaking to her
mother and teacher, Sasha could be
drawing her river, and inserting the
barriers that she perceives to be
holding her back as well as what she
views as supports. This is a way to get
her actively involved.
Assessment #1: I want to find out if the way Sasha Sensory Integration- The Sensory
Sensory Profile 2 processes sensory information Integration Frame of Reference looks at
has anything to do with her the way sensory integration affects
difficulties at school and socially. participation. By assessing this, we can
I will use this information to guide find ways to help Sasha learn to react
the way I write treatment plans more appropriately to sensory
for Sasha if it is determined that information.
she needs OT services.
Additionally, information from the
Sensory Profile may shed light on
Sasha’s behaviors and make it
possible to collaborate with her
parents and teachers on ways to
better meet her needs.
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Assessment #2: Through the use of the BRIEF, I MOHO-especially her performance
Behavior Rating will be able to determine if there capacity related to the items that will
Inventory of Executive are any concerns with executive be tested.
Function (BRIEF) function and self-regulation. This
test looks at both behavior and Sensory Integration-this model will
metacognition. This test assesses looks at self-regulation, and how
inhibition, ability to shift from one different sensory stimuli may affect
activity to another, emotional Sasha’s ability to self-regulate.
control, ability to initiate, working
memory, planning/organizing
events, organizing materials, and
the ability to monitor personal
performance. All of these factors
may affect Sasha’s participation.
If I can find out exactly where her
difficulties lie, it will be possible to
write more meaningful treatment
plans.
If more information is The SFA may be helpful to better MOHO-especially her performance
needed: School determine Sasha’s ability to capacity related to the items that will
Function Assessment perform functional tasks be tested.
(SFA) necessary in a school
environment. This test takes a
long time to administer, so I
would only recommend it if the
interview and other assessments
do not give us enough
information to fully help her.
4. Evaluation
In addition to previous information provided in the case, you now know the following pieces of
information from your evaluation:
• Teacher and mom both report that Sasha occasionally strikes out at people when they’re in her
space.
• She often chooses to hang back before and during transitions to activities. These are particularly
difficult times of the day for her. These behaviors also occur at home with greater intensity
when there is a sudden change in plans from the normal routine.
• Sasha tells you that she gets in trouble because she doesn’t get her school work done. When
you ask why she doesn’t get it done, she tells you that she hates handwriting and doesn’t
remember to bring homework to school. She also tells you that she forgets her lunch money and
gets in fights with kids at school and in the neighborhood.
• Sasha appears disheveled, trips on her own feet often, appears clumsy during recreational
activities such as tag, Chinese jump rope, and dodge ball.
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• Sasha has a good sense of humor, is talkative, and enjoys riding the suspended equipment in the
therapy room at school.
• When you observe her in class, Sasha frequently slouches in her desk or lays her upper body
down on her desk. She is easily distracted by things going on around her and she only finishes
1/3 of her worksheet.
• When a student next to her bumps her elbow, Sasha punches the student in the arm.
On another day, you obtain a handwriting sample and observe that Sasha uses a right handed tripod
grasp with thumb wrap. She uses very firm pencil pressure. She is able to copy a 12-word sentence from
near point in approximately 2 minutes with 50% legibility, 30% correct line orientation, 40% correct
sizing, and 20% correct between-word spacing. When asked to write a short paragraph on any topic of
her choosing, Sasha was observed to sit at the desk for several minutes without writing before she
became frustrated and stated “I can’t do this”.
In addition, a Sensory Profile was given to her teacher to complete and the following was found:
Quadrant Classification
Seeking/seeker Just like the majority of others
Avoiding/avoider Just like the majority of others
Sensitivity/sensory More than others
Registration/bystander More than others
Sensory Section Classification
Auditory processing More than others
Visual processing Just like the majority of others
Touch processing More than others
Movement processing Just like the majority of others
Body position processing Much more than others
Oral sensory processing Just like the majority of others
Behavior Section Classification
Conduct associated with sensory processing Much more than others
Social emotional responses associated with More than others

sensory processing
Attentional responses associated with sensory Much more than others
processing
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a) With all of this information in mind, write your occupational profile and analysis of occupational
performance for Sasha :
Occupational Profile
Sasha is a fifth grade student who is currently seeking occupational therapy services due to
difficulties in the classroom as well as concerns with social participation at school in spite of recent
adaptations put in place by the school psychologist. Sasha does not currently have a medical diagnosis,
but appears to have symptoms consistent with ADHD. Little is known about Sasha’s living situation. Her
mother is involved in academic decision making, but it unknown who Sasha lives with, if she has siblings,
and what their socioeconomic status is. Her father’s role in her life is unknown. It is undetermined if
she lives in a house or an apartment and if she has access to supportive resources outside of school.
According to both her mother and teacher, Sasha occasionally strikes people that get into her space, she
has difficulty with transitions, especially those that are unexpected, and she is not finishing her school
work. When asked why she does not finish her school work, Sasha replied that she “hates handwriting,”
and does not remember to bring her homework to school. She also forgets her lunch money. Sasha’s
mom notes that Sasha gets into altercations with other children in the neighborhood. When observed,
Sasha appeared disheveled, and is clumsy while playing games that require gross motor control. In the
classroom, she is easily distracted by her surroundings and only finished 1/3 of a worksheet she had
time to complete. She frequently slouches and lays across her desk. When bumped on the elbow by
another student, she punched the other student in the arm.
Sasha is a talkative child with a great sense of humor. She enjoys playing on equipment that is
suspended from the ceiling. She received occupational therapy in kindergarten, but was able to meet
academic expectations, and was released from OT services. Though she has struggled through the
years, up until the 4th grade, she was able to meet the expectations of the academic environment. She is
currently having difficulties completing her schoolwork in a timely manner, remembering her belongings
and homework, staying on task, finishing tasks, and following directions. She is also not participating
with peers at recess and her mother and teacher are concerned about her aggressive behavior. Sasha is
a daughter and student, and is having trouble performing these roles due to academic concerns as well
as her aggressive behaviors and difficulty with transitions.
Occupational Analysis
Sasha was asked to copy a 12 word sentence as well as write a short paragraph on the topic of her
choosing. She copied the sentence in approximately two minutes with 50% legibility, 30% correct line
orientation, 40% correct sizing, and 20% correct between-word spacing. Her performance of this task
was below the expectations for a child her age. Further assessment is needed to determine if difficulty
is due to attention, visual motor integration concerns, or something else. When asked to write a short
paragraph, she sat for several minutes and said “I can’t do this”. Her inability to complete the task may
be due to a variety of factors including inattention, dysgraphia, or lack of desire to complete the task.
Next, the Sensory Profile was administered to her teacher. The Sensory Profile is a standardized
assessment used to determine a child’s sensory processing patterns and how they may affect
performance at home, school, and in the community. It assesses a child’s threshold regarding sensory
stimuli. If a child has a high threshold, they are slow to notice sensory stimuli. If they have a low
threshold, they are quick to notice sensory stimuli. It also assesses whether a child is passive meaning
they allow sensory experiences to happen, then react to them, or if they are active meaning they
attempt to manage sensory experiences before they happen. Sasha received a score of “more than
others” in the Sensory/Sensitivity Quadrant meaning that she may react more quickly and intensely than
others to certain sensory stimuli. She also received a score of “more than others” in
Registration/Bystander Quadrant meaning that she may miss some sensory cues. Though these areas
appear contradictory, it is possible for a child to react strongly to some sensory input while missing
19
other types. For example, she may be sensitive to one type of sensory information such as sound, but
low registration for another type such as visual. This could explain why Sasha may overreact when
touched, but may miss certain social cues. Sasha experiences auditory information and touch
information more than others, and body position processing (proprioception) much more than others
meaning she is sensitive to sounds, touch, and proximity of others. According to the behavior section of
the Sensory Profile, Sasha exhibits conduct associated with sensory processing much more than others,
she also exhibits social emotional responses more than others, and does not pay attention to cues
around her much more than others do. Overall, Sasha exhibits problems with sensory processing that is
effecting her academic performance as well as social participation. She is also demonstrating concerns
with handwriting that are negatively impacting her academic performance and ability to stay on grade
level.
b) From the evaluation information you gathered, identify two specific areas of occupation that
Sasha is having difficulties with. For those two occupations, identify two client factors, two
performance skills, two performance patterns, two contextual factors, and two activity demands
that may limit Sasha’s participation in home, school, community, and/or vocationally related
activities. Be specific and relate information provided to you in case study to the categories you
select (i.e. Client factors: Specific mental functions-Child demonstrates decreased attention to
tasks during tabletop activities.)
Potential Limitations or Barriers

Occupations Formal Education Participation Peer/friend Social Participation
Client Factors (Table 2 of Attention- Sasha is easily Temperament and personality-

OTPF) distracted in the classroom by sometimes Sasha lashes out when
what is going on around her. bumped, or other children are in her
space. This indicates that she could
Mental functions of sequencing improve in self-control and impulse
complex movement-when asked control to have a more appropriate
to do an assignment, often reaction to this situation.
Sasha is unable to finish in the
time allotted, or her finished Sensory Functions-Sasha is sensitive
product is not of the quality to touch, body position, and auditory
necessary for academic stimulation. For this reason she may
competency. have a difficult time regulating herself
in a noisy situation, when touched
unexpectedly, or when there is too
much going on around her.
Performance Skills (Table Paces- Sasha has a hard time Touches- Sasha does not always
3 of OTPF) completing assignments she has respond to touch in a socially
started. acceptable way. For example, she hit
20
Inquires- Even with a student that accidentally bumped

modifications to instructions, her.
Sasha is not completing
assignments. This indicates that Places self- due to her dislike of
she may not know how to ask transitions, Sasha will hang back from
for additional instructions as the crowd instead of moving along
needed. with her classmates.
Performance Patterns Person/Routines -Sasha does Person/Roles- Sasha does not

(Table 4 of OTPF) not do well when there is a conform to the role of friend. She is
change in routine regarding how not getting along with her peers, and
transitions are made or when sometimes lashes out when touched.
they take place. She also gets in fights with other kids
at school and in the neighborhood.
Roles- Sasha does not conform
to the behaviors expected of a Person/Routines- changes in the
student. She is not finishing normal routine cause Sasha to act
assignments, her handwriting is out. Her reaction to transitions may
not on par with that of her be off-putting to her peers.
peers, she forgets to bring
homework back to school, and
she interacts poorly with her
classmates.
Contextual/Environmental Physical Environment- Sasha is Cultural Context- The school setting is

Factors (Table 5 of OTPF) uncomfortable when placed in considered a cultural environment
an unfamiliar environment. since there are certain expectations
Additionally, the school regarding the customs, beliefs,
environment may not be set up activity patterns, standards, and
in a manner conducive to her expectations within a school. Sasha is
learning capabilities. For currently having a difficult time
example, she is easily distracted assimilating to the expectations of
in the classroom. Is it possible this environment. She does not look
to change the area around her like the other students (is
to make it less distracting and disheveled), she is not participating
help her readiness to learn? with them in an expected manner
(lashes out, and strikes peers who get
Temporal Environment- Sasha is in her space, and often gets in fights,)
not fitting in with the rhythm of she is not conforming to the expected
the classroom. She is not filling patterns of the day, and she is not
her time in the way she is doing the expected schoolwork.
expected to, and is not
transitioning well when the Social Environment- Sasha is not
duration of an activity is participating well in the social
finished, and she is expected to environment at school or in her
neighborhood. She is not
21
move on to a new activity in the participating with her peers at recess,

sequence of the day. and gets in fight with kids at school
and in her neighborhood. Neither
her mother nor her teacher have said
anything about whether Sasha has
any friends that she plays with at
school or at home. All information
given about Sasha’s social
participation has been negative.
Activity Demands (Table 7 Relevance and importance to Social Demands-We can work with
of OTPF) client- at this point, we do not Sasha to help her recognize what
know what Sasha views as expected behavior looks like and
relevant and important to her at teach her how to better conform to
school. Is she trying her best, or the social norms of the school setting.
does she have a bad attitude Behaviors like hanging back during
about school? What does she transitions, and hitting other students
like/dislike? If we know more are not socially acceptable, and may
about what Sasha views as make it difficult for Sasha to make
important, we can better assist friends, or participate in games at
her in the classroom. If we find recess.
that she really likes My Little
Pony, we can make tasks like Relevance and Importance to client-
handwriting more meaningful by We have not heard from Sasha
having her write about ponies, regarding her feelings about her
and earn pony related prizes peers at school and in the
when she stays on task. neighborhood, but I feel it is safe to
assume that most 10 year olds want
Required Actions and to have friends. It is likely that Sasha
Performance Skills- Sasha is places importance on having
having a difficult time with playmates that share similar
handwriting. She pushes too interests. It is imperative to find
hard when she writes, produces ways to improve her social skills and
work that is only 50% legible mitigate her sensory concerns so that
and her spacing and sizing is it is easier for her to have age
below average for her age. appropriate relationships with other
Additionally, wrapping her children.
thumb with a tri-pod grasp may
be causing fatigue. In therapy,
we can help improve her
handwriting, or find alternative
ways for her to complete
assignments such as typing or
speech to text. If we can find a
way to make her more
successful, her academic
22
achievement may improve

overall.
c) From the evaluation information you gathered, identify two specific areas of occupation that are
strengths for Sasha. For those two occupations, identify two client factors, two performance
skills, two performance patterns, two contextual factors, and two activity demands that may
support Sasha’s participation in home, school, community, and/or vocationally related activities.
Be specific and relate information provided to you in case study to the categories you select (i.e.
Client factors: Specific mental functions-Child demonstrates decreased attention to tasks during
tabletop activities.)
Potential Strengths or Supports

Occupations Occupation #1 Occupation #2
Formal Education Participation- Peer/friend Social Participation -
in spite of her current Sasha was observed participating in
difficulties, Sasha appears to tag, Chinese jump rope, and dodge
attend school regularly, and is ball. This indicates that she is willing
supported by her mother, school to try a variety of play activities that
psychologist, and teacher who are age appropriate and take place
are all trying to find ways to help with two or more other people.
Sasha continue to stay on grade Though there are some definite social
level, and meet academic concerns for Sasha, it appears that
expectations. Sasha has she is capable of participating, and
experienced difficulties in the willing to try a variety of playground
past, and managed to overcome games with other children.
them. She was even able to
transition out of OT when she
was in Kindergarten.
Client Factors (Table 2 of Sensory Functions/Visual Control of Voluntary Movement-
OTPF) functions -According to the Sasha (though clumsy) has adequate
Sensory Profile, Sasha’s visual hand-eye, and foot-eye coordination
processing skills are “just like the to play a variety of playground games
majority of others”. This means with other students. She also
that Sasha’s ability to make appears to have the oculomotor
sense of visual information control and fine/gross motor control
taken in through the eyes is necessary to play games such as
considered normal. This may Chinese jump rope that take a high
indicate that Sasha’s level of control. Her coordination
handwriting difficulties likely do and voluntary muscle control will
not stem from visual processing translate to an assortment of play
concerns. This also means that activities at recess. Additionally,
utilizing helps like visual these skills will help support her
schedules to make transitions social success because control of
easier, and providing voluntary movement is important to
information in visual formats
23
may be helpful for Sasha since tasks such as carrying a cafeteria tray
her body processes this to go sit with other children at lunch.
information well.
Voice and speech functions- Sasha is
Temperament and Personality- talkative and is able to communicate
Though there are portions of her concerns with others. She told
Sasha’s temperament and the therapist that she “hates
personality that are barriers to handwriting” and that another
her success, she also has some activity was “too hard.” Being able to
aspects that will support her communicate her needs and
occupational performance. frustrations verbally in a healthy,
Sasha has a good sense of expected way is going to make it
humor which will help make the easier for Sasha to initiate and
therapy process easier for her, maintain social interactions with
and as her therapist, I can use other children. In therapy, we may
humor as part of my therapeutic be able to work on “using her words”
use of self. Additionally, she is instead of hitting when frustrated or
talkative. This aspect of her startled.
personality will make it easier to
learn about what she needs,
how she perceives herself, what
her concerns are, and what she
wants to accomplish in school
and in OT. A talkative child may
be easier to reach than a child
that is more reticent.
Performance Skills (Table Uses- It appears that Sasha Takes turns- Sasha participates in
3 of OTPF) knows what tools and materials games that involve turn taking.
to use for specific tasks in the These include Chinese jump rope,
classroom. If she did not, she dodgeball, and tag. This is
would not have made it to 5th instrumental in being able to
grade. participate socially with friends at
recess, or at parties and get-
Produces Speech- Sasha speaks togethers outside of school.
in a manner that can be
understood by her mother and Discloses- Sasha is able to disclose
teachers. This skill makes it easy her thoughts and feelings to the
to understand what she needs therapist as well as her teacher. It is
when she verbalizes. She is was assumed that this skill transfers to
able to tell the therapist that she social participation since we know
forgets lunch money and also that Sasha is good about this in other
gets in fights. settings.
24
Performance Patterns Roles- Though she has some Rituals- Though difficult for her at
(Table 4 of OTPF) struggles, Sasha fills the role of a times, it appears that Sasha
student. She attends school participates in the expected ritual of
regularly, and is seeking services playing with other children at recess.
to increase her ability to She has been observed playing a
perform her student role more variety of social games at school.
competently.
Roles- The role of friend is one that
Routines- Aside from difficulty Sasha appears to want, but does not
with transitions where she holds know how to perform competently.
back a little bit, Sasha does Her desire to be a friend, and play
everything her classmates do with other children will help motivate
during the course of the day. her to learn ways to increase her role
She goes to school, goes to competency. Increased role
recess, goes to lunch, and competency will enable her to have
attends assemblies etc. with her more diverse social interactions
class. This is something to interactions. For example, if Sasha
commend her for because it is interacts appropriately with other
well known that following this children at school, she may be invited
routine is very difficult for her, to a birthday party on the weekend.
but she does it anyway.
Contextual/Environmental Physical Environment- The Physical Environment- The school
Factors (Table 5 of OTPF) school works as a support to offers ample areas for children to
Sasha. It is an institution set up play together, and participate in a
for learning, and appears to variety of games and sports.
have the supports necessary for Additionally, the cafeteria and
her. For example, the therapy classroom offer space for social
room has suspended equipment interactions with each other. For
which she appears to enjoy. She example, she make work on a group
also has access to special project in the classroom, or sit with
education classrooms as well as other students to eat lunch.
general education classrooms
and a playground. Wish some Social Environment- Recess and
adaptations to eliminate lunch are times where Sasha can
distractions, we can make this actively play and interact with other
an optimal place of learning for children.
her.
Social Environment- The school

offers a safe, accepting, inclusive
environment for a variety of
children to learn in.
Activity Demands (Table 7 Space Demands- The school Relevance and importance to client-
of OTPF) offers the space necessary for Social participation with peers and
academic success. friends is important and relevant to
children Sasha’s age who count on
Objects Used and their friendships to meet a social need.
properties- The school provides
25
the supplies necessary to Her ability to play with other children

achieve academic success. will increase her social participation.
Required body functions- It Object’s used and their properties-

appears that Sasha has the the tools and toys necessary to play
required body functions to be with other children are available to
successful at school with some Sasha. By having these available, it
modifications and supports to makes it easier to participate in play
help with handwriting, which may improve and increase
attention, and sensory social opportunities for her. Having
processing. opportunities to play cooperatively
with other children will ultimately
help Sasha learn appropriate social
behavior which will increase her
competency and lead to more (an
higher quality) social interactions.
d) Projected Outcomes
Identify and describe appropriate projected outcomes (Table 9) based on family’s priorities,
occupational profile, evaluation, and analysis of occupational performance. Only identify those
pertinent to the case.
Occupational Prevention Health & Quality of Life Participation Well-being

Performance Wellness
-Sasha will -By addressing - By -By improving -By helping -By

improve her late assignments refining her school Sasha find ways improving
ability to turn and the reasons Sasha’s performance by to complete her ability
in completed for them now, social completing assignments and to turn in
assignments further interactio assignments on turn them in on assignmen
in a timely academic ns with time, Sasha’s life time, she will ts, Sasha
manner. decline will be peers, satisfaction and increase her will be
prevented. Sasha’s self-concept will level of more
-Sasha will social increase. participation in content
improve her -Improving well-being the classroom to with her
tolerance to social will be -By being better what is expected ability to
changes in interactions improved. equipped to of her. meet
routines and with peers will Social handle changes academic
tolerance of prevent future well-being to routine and -Improving expectatio
transitions. isolation and is an transitions, tolerance of ns which
loneliness. important Sasha will be changes in will
-Sasha will aspect of more satisfied routines will improve
26
improve -Improving health and with her life allow Sasha her well-
social tolerance to wellness experiences. more being.
interactions change will which opportunities to
with peers, prevent future extends -By having try new things -By having
and will no difficulties with beyond improved and and participate improved
longer lash transitions and the person meaningful in new activities.social
out when change that may to groups social interaction
frustrated or have a larger and interactions, -By improving s, Sasha’s
touched impact on her populatio quality of life social self-
unexpectedly life than what is ns as well. will increase interactions with esteem,
. expected of a because these peers, Sasha will role
child. For interactions are have more competenc
example, an elemental in opportunities to y, and
adult who does building self- play with other sense of
not do well with esteem, feeling children, and security
changes in included, and work with them will
routine may not feeling needed. in the classroom improve.
be able to hold a on assignments.
job for long. By
addressing this
now, we are
preventing
worse problems
in the future.
5. Intervention Process: Develop a Plan
a) Based on evaluation information, list three priority intervention/goal areas for Sasha.
1. Completing and turning in assignments in a timely manner.
2. Improving her tolerance of changes in routines, and during transitions.
3. Improving social interactions with peers.
b) Selecting one of your priority intervention/goal areas for Sasha listed above, write one long term
goal and two supporting short term goals for Sasha. Be sure goals are in SMART/COAST format.
• Annual Long Term Goal 1: By the end of the school year, Sasha will turn in 9/10 of her
completed classroom assignments including homework with only daily verbal reminders
from her teacher to do so.
27
o Short Term Goal 1: Within 9 months, Sasha will independently ask her teacher for
additional directions as needed 5/5 times to fully complete her assignments.
o Short Term Goal 2: Within 6 months, with moderate assistance from the therapist,
Sasha will identify a minimum of four distractions in the classroom and at home that
prevent her from completing schoolwork.
c) Identify the practice models that you will utilize to guide intervention and activity selection in
order to accomplish your established goals. These may or may not be the same as the practice
models you selected to guide your evaluation
• Review your choice of an organizing practice model (PEO, MOHO, OA, EHP, Lifestyle Balance). Is
it still a good choice to guide intervention for your client? (If not revise your choice)– Justify and
provide a rationale for your choice with research/readings support your choice for this child.
(see below)
• Choose at least 2 (two) complementary OT models that will help guide you in the overall
intervention process. Be specific. List only those most pertinent. Justify and provide a rationale
for each one with research/readings support your choice for this child. (See below)
• Scientific Reasoning and Evidence: What researched evidence is available to help you with your
evaluation and/or treatment process? Give references to readings or research.
Practice Rationale:
Models
Briefly Describe the practice model and postulates Explain how these models address the goals and
for change. Describe how postulates of change overall outcomes you identified for this child.
are relevant to child/family. **Use research articles to support your rationale.
Organizing: PEO recognizes that occupational performance The ultimate goal of the PEO model is improving
Person- emerges from a transaction between people, their occupational performance. According to Brown
Environment- occupations, and the environment. With this (2009) you can use the PEO model to plan
Occupation model, we can look at how the environment interventions that help the client acquire new
Model (PEO) provides supports and barriers to Sasha’s ability to skills, remediate impairments, and adapt the
complete and turn in schoolwork. We can also occupation. We will be using this approach to help
look directly at the occupation of education, and Sasha meet her goal to get her schoolwork
what aspects of education a can be modified to completed and turned in on time. We can help her
better meet Sasha’s needs. acquire the new skill of using a planner to keep
track of assignments, we can find ways to help
The following postulates of change relate directly remediate her impairments such as teaching her
to Sasha. ways to cope with sensory sensitivities so that she
can function at school, and we can adapt the
- A person’s perceptions and beliefs about the occupation. For example, if her handwriting
environment and occupations influence cannot be improved to be more legible, we can
subsequent occupational performance; therefore it adapt her assignments so they are typed instead.
is important to understand person’s priorities and
perspectives. It is important that we understand See below the chart for references.
how Sasha perceives her environment as well as
her occupational performance. We need to find
28
out what she sees as important in order for her to

take an active role in therapy.
- Barriers to occupational performance can be

prevalent in the individual’s environment, and
interventions applied to the environment may
enable the individual’s occupational performance
in the presence of disability. It is important that
we identify barriers to Sasha’s occupational
performance and intervene to make her
environment as functional as possible for her.
- Change in person, environment or occupation, or

their transaction, can improve occupational
performance. We need to see the dynamic
interactions between P-E, P-O, and E-O and
determine how changes to any of these
interactions can improve Sasha’s occupational
performance.
- The environment is easier to change than the

person. When possible, it might be better to adapt
the environment, for example, seating Sasha closer
to the teacher, would be easier than teaching her
strategies to pay closer attention when the teacher
gives instructions.
Complementary The Acquisitional Model is used to develop Watling and Schwartz (2004) investigated the use
#1: Acquisitional functional skills for occupational engagement. This of Applied Behavioral Analysis (ABA) for children
is done by mastering skills, subskills, and with disabilities. A key component of this
appropriate behaviors. approach is the use of positive reinforcement.
They discuss that when a child is working on
The following postulates of change relate directly establishing behavior, it is most effective if
to Sasha and can be used to guide intervention. reinforcement is delivered every time the desired
outcome occurs. Once the child becomes more
- If the therapist provides positive reinforcement skilled, the reinforcement schedule can be changed
specific to the child and the environment, then the to be more intermittent. They found that using this
child will be more likely to acquire component approach of positive reinforcement is highly
steps of skills or specified skills. If Sasha receives effective to modify behaviors in children with
positive reinforcement for her efforts, she will developmental disabilities including ADHD. In
begin to acquire the skills necessary for better Sasha’s case, we can use positive reinforcement to
participation. help her gain the skills necessary to meet her goal
about turning her assignments in on time. We can
- If the therapist uses various schedules of initially reward Sasha for sitting for a period of
reinforcement specific to the child and the time and working on her assignment. Once that
29
environment, then the child will be more likely to becomes an ingrained skill, we can reward it more
acquire component parts of skills or specified skills. intermittently, and begin to have her work on
Sasha will initially be rewarded for all attempts to something else that will help move her closer to
participate in a new activity, or develop a new skill. her ultimate long term goal. Additionally, the
Once she begins to become competent in this skill, Acquisitional model can be used to help increase
reinforcement will become intermittent, then be her social competency. According to Watling and
extinguished. Schwartz, ABA can be used to increase positive
social interactions in children with disabilities.
- If the therapist provides reinforcement for any
attempt at a behavior, then the child is more likely See below the chart for references.
to acquire the behavior. Initially, by rewarding all
of Sasha’s attempts, she will be more engaged.
- If the therapist reinforces component parts of a

skill, then behavior will be shaped so the child can
acquire the skill. Some of the skills Sasha needs to
learn are broken down into smaller sub-skills. For
example, to meet her long term goal of turning in
her assignments on time, she will need to learn to
ask for help as necessary. She will be rewarded for
approximating the short term goals necessary for
her success with her long term goal.
- If a child acquires specific skills and those skills

are reinforced, then the skill has the potential of
being self-reinforcing and generalized to other
settings. Sasha will be rewarded until she is
intrinsically rewarded for completing a skill.
- If reinforcement is consistent across settings,

then skills are more likely to be acquired. OT will
work with Sasha’s teacher and mother to make
sure rewards for certain behaviors are consistent
across settings.
Complementary The 4QL model is utilized to enhance occupational Per Greber, Ziviani, & Rodger (2007), “The 4QM
#2: Four performance through the use of specific teaching provides a structure that can enhance the
Quadrant Model and learning techniques to increase the mastery of knowledge used to inform clinical reasoning when
of Facilitated occupational skills necessary for the intended task. using learning strategies as part of a teaching–
Learning (4QL) The four quadrants of this model include Task learning approach to intervention.” Each quadrant
Specification (1), Decision Making (2), Key Points of this approach can be used to help Sasha meet
(3), and Autonomy (4). Quadrant one includes her therapy goals. Quadrant one is an instructor
explicit instruction, demonstration, physical led approach that gives explicit instructions.
patterning and lower order questions. Quadrant Quadrant two uses more indirect strategies to help
two includes higher order questions, feedback, the learner engage in the decision making process.
physical prompts, non-verbal prompts, and think Quadrant three is a learner driven process that
aloud modeling. Quadrant three utilizes priming, focuses on strategies such as self-talk and picture
30
mnemonics, verbal self-instruction, visual cues and cues that the leaner may use to enable their own
kinesthetic self-prompting. Quadrant four teaches performance. In the fourth quadrant, the learner
the use of mental imagery, self-instruction, self- scaffolds their own experiences. Altogether, this is
questioning, self-monitoring, problem solving, and a multifarious approach to teaching and learning
automaticity. This model is effectively used with that helps the child become an independent critical
children who have deficits in their ability to acquire thinker. Additionally, with this model, Sasha can
new skills but want to independently complete learn to self-advocate when she needs further
daily occupations. instruction or information to complete an
assignment.
The following postulates of change from the 4QL
frame of reference apply directly to Sasha. See below for references.
Postulates of change are from Kramer & Hinojosa
(2010).
- If the therapist uses facilitator-initiated methods

such as explicit instruction, explanation, physical
patterning, and lower order questions, then the
child will be able to understand the characteristics
of the task and/or performance that is needed. A
variety of methods from all four quadrants will be
used to help Sasha increase her performance.
-If the therapist uses additional facilitator-initiated

methods like higher order questions, feedback,
physical prompts, lack of verbal prompts, and
thinking aloud modeling, then the child will be
encouraged to make decisions regarding the task.
Sasha will be encouraged to be an active
participant by answering higher order questions,
and finding ways to tackle a task independently.
- If the therapist encourages the child to engage in

learner-facilitated strategies such as priming,
mnemonics, verbal self-instruction, visual cues,
and kinesthetic self-prompting, then the child will
be able to recall key points essential to task
performance. By teaching Sasha a variety of
strategies she can use independently, she will be
able to participate more fully in the academic
environment.
- If the therapist encourages and helps the child to

use learner-initiated strategies such as mental
imagery, self-instruction, self-questioning, self-
monitoring, problem solving, and automaticity,
then the child will be able to perform the task
autonomously. Sasha will use a variety of methods
31
to learn how to perform tasks independently and

problem solve.
- If the therapist uses intermediate strategies to

move the child from facilitator initiated to learner
initiated and from direct strategies to indirect
strategies, then the child will be able to go from
one quadrant to the next quadrant. Sasha will be
taught a variety of strategies to be able to navigate
all four quadrants as necessary to be successful at
a task.
References for the Above Table
Law, M., Cooper, B., Strong, S., Stewart, D., Rigby, P., & Letts, L. (1996). The Person-Environment-
Occupation Model: a transactive approach to occupational performance. Canadian Journal of
Occupational Therapy, (63), 9-23.
Brown, C. (2009). Functional assessment and intervention in occupational therapy. Psychiatric
Rehabilitation Journal, 32(3), 162-170. doi:10.2975/32.3.2009.162-170
Watling, R., & Schwartz, I. S. (2004). Understanding and implementing positive reinforcement as an
Intervention strategy for children with disabilities. American Journal of Occupational Therapy,
58(1), 113-116. doi:10.5014/ajot.58.1.113
Greber, C. & Ziviani, J. (2010). A frame of reference to enhance social participation. In P. Kramer, & J.
Hinojosa (Eds.), Frames of reference for pediatric occupational therapy (3rd ed., pp.306-348).
Philadelphia, PA: Lippincott Williams & Wilkins.
Greber, c., Ziviani, J., & Rodger, S. (2007). The four-quadrant model of facilitated learning (part 1): using
Teaching learning approaches I occupational therapy. Australian Occupational Therapy Journal, (54),
31-39. doi:10.1111/j.1440-1630.2007.00662.x
d) Service Delivery:
• What type(s) of services do you anticipate will best meet Sasha’s needs?
(Direct/Consult/Collaboration/Co-treat, etc.)
Type(s) of service Rationale:

Direct By working with Sasha directly, I will be able to tailor treatment
specifically to her where in the classroom, this is not possible.
Each child has different needs that cannot always be met in a
room with 20+ other students. Additionally, it will give me an
opportunity to better assess her sensory concerns and work with
her to find ways to cope at school so that ultimately, she will be
more successful.
32
By collaborating with her teacher, mother, and other

Collaboration professionals at the school, we can be sure that Sasha receives
consistency regarding interventions implemented in therapy. For
example, if I teach Sasha how to use a planner, it will be
imperative that her teacher also knows how this system works,
and that her mother is familiar with it as well. If both her mom
and teacher check her planner to make sure Sasha is using it,
there will be more consistency from Sasha until she can
competently use the planner independently.
• What setting(s) will the services take place (be sure to consider all of the information from
the case so far)?
o This is a school referral, so services will take place at school, but Sasha’s mother will
have input regarding priorities for treatment as long as her ideas relate directly to
Sasha’s participation at school. Unfortunately, since Sasha will be seen in the school
setting, we will be limited to what can be done in therapy because concerns
addressed must directly impact her academic performance.
• What is frequency & length of services?

o Sasha will be seen for 30 minutes per week for the entire school year. This will give
her a total of 120 minutes per month unless she misses OT due to a school holiday.
6. Implement the Plan

a) Treatment Sessions: Plan your first two 30-minute treatment sessions.
Treatment Session #1:

What goal are you addressing? By the end of the school year, Sasha will turn in 9/10 of her
completed classroom assignments including homework with only daily verbal reminders from her
teacher to do so.
Intervention Description (Be very specific. Indicate that you understand how the postulates of
change from your chosen practice models will bring about change in the client during your session,
as well as what your role as the OT is during the session. In other words, how is this a skilled
service?):
Warm Up 5 Minutes: Sasha will swing in a prone position while attempting to throw beanbags
through hoops held by the therapist. This is an activity Sasha enjoys which will help establish her
interest in the therapy session. Additionally, it will play a role in promoting learning by having a
calming effect on Sasha so she can focus on the rest of the session.
-Postulates of Change used for this activity:
From the Sensory Integration FOR: “If a therapist offers sensory opportunities for at least two out of
three systems (tactile, vestibular, and proprioceptive), then therapy will provide a supportive
environment in which a child can learn to self-regulate and be aware of sensory stimuli.” (Schaaf et
al., 2010, p.151) Through this activity, Sasha will receive tactile, vestibular, and proprioceptive
feedback. This will help her regulate her emotions while participating in therapy. From the Sensory
Integration FOR: “If the therapist helps the child attain and maintain appropriate levels of alertness
and affective state, then the child will be more likely to sustain engagement in therapeutic activities.”
33
(Schaaf et al., 2010, p.151) By being proactive and starting the session with an activity that is both
interesting to Sasha as well as regulating, the session will overall be more successful.
-Set up: The swing will be hanging from the ceiling in the therapy room with a safety mat beneath it.
Beanbags will be scattered around the room, and hoops will be held by the therapist so that distance
can be graded as necessary.
-Name of activity: Swing
-Ways to grade up: change the distance needed to throw, have her pick up objects from the floor
before throwing, or time the activity and see if she can beat her prior time.
-Ways to grade down: shorter throwing distance, hand beanbags directly to Sasha.
-Materials: swing, bean bags, safety mat, and hoops
Main Activity 15-20 Minutes: Sasha will help make and begin to use a planning notebook in order to
keep track of assignments and due dates. Sasha will decorate a three ring binder that includes a daily
task list, a weekly schedule, and a monthly calendar. She will be taught to write down assignment
due dates on the monthly and weekly calendars, and make a daily check list of what needs to be done
in order to finish her assignments in a timely manner. She will be taught how to check off completed
tasks, and move items she did not complete to the next day where they will be prioritized so they do
not become past due. Changes in schedule will be noted in this book so that Sasha is not taken by
surprise by activities such as assemblies that cause an unexpected transition which is difficult for her.
Sasha will be encouraged to keep this notebook with her at all times, and to refer to it any time she is
given an assignment or completes a task from her checklists. Since this is her first introduction to this
organizational strategy, her mother and teacher will be encouraged to look at the planner daily to
make sure Sasha is filling it out correctly, checking off completed tasks, and turning in completed
assignments. Sasha will be rewarded with stickers each time her teacher or mother finds that she is
up to date on everything and making a consistent effort to use the notebook. Approximations of this
skill will be rewarded until Sasha becomes proficient. Once proficient, Sasha will be rewarded for
correct use. When Sasha gets 10 stickers, she can bring them to the therapist for a prize.
Additionally, though handwriting is not being specifically addressed in this session, Sasha will be
encouraged to use her best handwriting in this notebook in order for it to be easier to stay organized.
From PEO -“Barriers to occupational performance can be prevalent in the individual’s environment,
and interventions applied to the environment may enable the individual’s occupational performance
in the presence of disability.” By providing an intervention that will help Sasha organize her school
work, she will be able to keep track of her assignments, make lists of what needs to be done, and
ultimately turn her work in on time.
From the Acquisitional Model- “If a child acquires specific skills and those skills are reinforced, then
the skill has the potential of being self-reinforcing and generalized to other settings.” By rewarding
Sasha for her efforts to fill out her notebook, she will eventually start using this system in other
settings, and will begin to be intrinsically rewarded by her efforts. “If reinforcement is consistent
across settings, then skills are more likely to be acquired.” For this reason, Sasha’s mom will reinforce
the use of the notebook at home, the teacher will reinforce its use at school, and the therapist will
provide rewards.
-set up: Sasha will sit at a table where she will be able to choose the color of her binder, and decorate
it with stickers.
-Name of activity: Making a Plan
-Ways to grade up: Teach Sasha how to prioritize tasks, have Sasha use the notebook to organize
after school activities and chores as well as school assignments.
34
-Ways to grade down: Fill out the notebook for her

-Materials: Notebook, printed calendar sheets, printed task lists, a copy of the school’s scheduled
activities and Sasha’s known homework.
Wrap Up 5-10 Minutes: The therapist will administer the Wilbarger Protocol to help reduce Sasha’s
tactile defensive behaviors that occur when she is touched unexpectedly. Sasha is sensory sensitive in
touch processing which may be why she lashes out when touched. It also may be why she has a
difficult time with transitions and hangs back from her classmates. If Sasha is able to tolerate
brushing and joint compressions, she will be taught how to brush herself, and her mother will be
taught the entire protocol.
From Sensory Integration “If the therapist utilizes an achievable challenge to sensory modulation,
discrimination, and/or integration, then the child will achieve enhanced development in that area of
challenge.” (Schaaf et al., 2010, p.151) Through the use of the Wilbarger Protocol, Sasha will reduce
her tactile defensive responses to unexpected touch. This will lead to more positive peer interactions,
and Sasha will be more comfortable during hallway transitions where she may be bumped by other
students.
From Sensory Integration “If a child is over-responsive, under-responsive, or seeking sensory stimuli,
then intervention must be directed initially toward facilitating an appropriate adaptive response to
those sensory stimuli which are producing the maladaptive response. (Schaaf et al., 2010, p.153)
Brushing will be used as a technique to encourage Sasha to have a more adaptive response to being
touched.
-set up: Sasha will sit in a comfortable position and distractions will be eliminated to the extent
possible.
-Name of activity: Wilbarger Protocol
-Ways to grade up: Teach Sasha to administer the brushing to herself, extend the amount of time
spent on the protocol.
-Ways to grade down: Shorten the amount of time spent on the activity.
-Materials: surgical brush
Setting Activity Demands (table 7) Anticipated outcome (what

skills you expect to observe
change in based on your
session):
Activity demands of warm up: Relevance and Outcome of warm up: Sasha
This session Importance to client-Sasha likes this activity will improve her focus and be
will take able to remain emotionally
place in the Objects used and their properties-The swing is used regulated and engaged for the
therapy as a support to occupational performance by being rest of the session. Inattention
room at the a regulating and preferred activity will be prevented for the rest of
school. the session by taking the time
Space demands- the room needs to be large enough to help Sasha become regulated
to safely swing in. and focused.
Sequencing and Timing- In order to throw the Outcome of main activity:

beanbags through the hoop, Sasha needs to time Sasha will begin to organize her
her throws with the way the swing is moving. schedule and how she manages
35
her time which will lead to

Required body functions-Sasha will rely on a variety improved ability to turn in
of cognitive functions in order to adjust throwing assignments in a timely manner,
speed/distance. and will help with transitions
which will now be expected
Required body structures-Sasha has all the rather than unexpected.
structures required to participate in this activity.
Outcome of wrap up: Sasha will
Activity demands of main activity: Relevance and exhibit a more adaptive
importance to client-by keeping an assignment response to unexpected tactile
notebook, Sasha will become more independent in stimulation. This will improve
her ability to complete assignments. her participation in school
activities and improve her
Social Demands-Sasha can also use this notebook to quality of life due to lower
keep track of and organize social activities such as stress response signals.
play dates.
Sequencing and timing-Sasha will learn how to

decide what steps of an assignment need to be
completed in which order to be most effective.
Required body functions-executive functioning skills

are necessary to make a plan and follow it through.
Required body structures-Sasha has all the

structures required to participate in this activity.
Activity demands of the wrap up: Relevance and

importance to client-Sasha would like to have a
more adaptive response to being touched, and have
less stressed response to crowded spaces.
Required body functions-brushing will cause a more

adaptive response to tactile stimuli.
Intervention Approach (Table 8 of OTPF): Intervention Type (Table 6 of OTPF):

Intervention approach for warm up: Intervention type of the warm up:
Establish/restore- Swinging helps Sasha establish Activity-swinging helps Sasha be more engaged in
focus for the rest of the session. her therapy session.
Prevent-this activity will prevent Sasha from Preparatory Task-This activity helps Sasha
losing interest in therapy and prevent her from prepare for the rest of her session.
losing focus early in the session.
Education-Swinging helps Sasha be more
Intervention approach for the main activity: engaged in school related tasks by helping her be
Create/Promote- Sasha will create a tool to help more regulated and attentive.
36
her stay engaged in her learning and aware of

what is going on at the school. Intervention type of the main activity:
Establish/restore-Sasha is establishing a habit of Education-Sasha will be taught a strategy that will

organizing her day and assignments that will help help improve her participation at school.
her through her academic career as well as on
the job in the future. Self-Advocacy-by being aware of transition that
are upcoming, Sasha can work with her teacher
Prevent-Sasha will prevent some of the distress and OT to come up with a plan to handle them.
associated with transitions by having them
written in her planner where she can see they are Intervention type of the wrap up:
going to happen, and she will not be taken by Preparatory method- the Wilbarger protocol
surprise. prepares Sasha to participate in the classroom in
a more socially appropriate way.
Intervention approach for the wrap up:
Promote-The Wilbarger protocol will promote
change to Sasha’s nervous system that will allow
her to have more adaptive responses to tactile
stimuli.
Practice Model(s)
Practice Model used for the warm up: The Sensory Integration FOR was used because outcomes of
this model include “self-regulation to regulate and maintain an arousal level and or an activity level
needed to appropriately attend and focus on the task or activity; maintaining postural control
including muscle tone, strength and balance, ocular control, and bilateral coordination and laterality;
adequate praxis; and development of self-esteem and self-efficacy” (Schaaf et al., 2010, p. 126) The
main use for this model was to increase Sasha’s focus and attention for the rest of the session,
however, she has some postural concerns (flops over on her desk and is clumsy) that can also be
improved with this activity which will build core strength and stability. Praxis is addressed through
the problem solving process required to pick up a bean bag, calculate throwing distance, and adjust as
needed. Through trial and error, Sasha will become successful at this activity which will help improve
her self-esteem and self-efficacy.
Practice Model used for the main activity: PEO was used as an organizing model because its overall
outcome is to help “Those who are not satisfied with their occupational performance because of a
lack of congruence between person, occupation, and environment.” By implementing the notebook,
and its lists, Sasha will be able to bridge the lack of congruence between herself and her occupation
(education).
The Acquisitional model is used to help develop functional skills. By rewarding Sasha’s attempts to
use the notebook, she will become better at filling it out which will ultimately lead to her ability to
complete and turn in assignments in a timely manner.
Practice Model used for the wrap up: The Sensory Integration model was utilized for this intervention
due to its focus on sensory modulation and integration. Sasha exhibits maladaptive behaviors when
touched. This is leading to social problems at school and causing her to get into fights with other
children. By improving Sasha’s reactions to tactile stimuli, she will be better able to participate in a
classroom, and in extracurricular activities with other children.
Rationale & evidentiary support for use of interventions/activities
37
Rationale and evidence for the warm up: Per Schaaf, Hunt, and Benevides (2013), using a
sensory integration approach in therapy helps improve participation at home, school, and in family
activities in children with autism. This study showed improvement in participation using parent-rated
goal attainment scales. Though Sasha’s diagnosis is unknown, she struggles with sensory concerns as
well as attention difficulties. This article supports the use of the swing to increase participation.
Rationale and evidence for the main activity: Hahn-Markowitz, Manor, and Maeir (2011) looked at
the effectiveness of Cognitive Functional (Cog-Fun) Interventions for children with ADHD. Their goal
was to address executive function which is often a deficit associated with ADHD. They found that by
improving executive function, children scored better on the COPM and BRIEF three months post
intervention. Interventions emphasized metacognitive strategies, self-evaluation, and self-
monitoring. Sasha’s notebook provides a metacognitive approach she can utilize to monitor and
evaluate her progress regarding academic tasks.
Rationale and evidence used for the wrap up: Kimball et al. (2007) completed a study on children
with ADHD and Sensory Defensiveness using the Wilbarger Protocol as the intervention. In all four
participants, the application of the Wilbarger protocol modulated their cortisol levels to a more
desirable level. For some of them, this meant an increase in cortisol levels, for some it meant a
decrease. For all, the results showed changes in the desired direction. Evidence lends support to the
use of the Wilbarger Protocol for Sasha who may have undiagnosed ADHD as well as Sensory
Defensiveness.
Treatment Session #2:

What goal are you addressing? Within 12 months, Sasha will demonstrate improved emotional
regulation by transitioning to and completing a non-preferred task with no more than 2 verbal
prompts, and no amount of adverse reactions 75% of the time.
Intervention Description (Be very specific. Indicate that you understand how the postulates of
change from your practice models will bring about change in the client during your session, as well
as what your role as the OT is during the session. In other words, how is this a skilled service?):
Warm Up 5 minutes: Sasha will be asked to race through an obstacle course set up in the therapy
room while riding prone on a scooter. This will be a fun activity for Sasha to increase her interest in
the session. Additionally, it will play a role in promoting learning by having a calming effect on Sasha
so she can focus on the rest of the session. This activity provides deep pressure through the joints
which is regulating to Sasha.
From the Sensory Integration FOR: “If the therapist provides challenges to the child’s ability to
conceptualize and plan novel motor tasks, then the child will be more likely to develop praxis and the
ability to organize his/her behavior in time and space” (Schaaf et al., 2010, p.151). This activity works
on regulating Sasha’s nervous system so that she is calmer and better able to pay attention.
From the Sensory Integration FOR: “If the therapist helps the child attain and maintain appropriate
levels of alertness and affective state, then the child will be more likely to sustain engagement in
therapeutic activities” (Schaaf et al., 2010, p.151). By taking a few minutes to help Sasha attain an
appropriate level of alertness, she will be able to better attend to the rest of the session.
-set up: Cones will be used to mark a course through which Sasha will race on the prone scooter.
38
-Name of activity: Scooter

-Ways to grade up: Make the course longer, add turns to the course, time how fast she goes through
the course then have her beat her record, have Sasha go through the course backwards.
-Ways to grade down: Shorten the course, keep the course straight.
-Materials: Scooter and cones.
Main Activity 20 Minutes (may take longer and need to be finished in a later session): The client will
create a social story to establish appropriate reactions to being touched unexpectedly by a peer, and
a story addressing ways to make transitions easier for her. Stories will be written and drawn like a
comic strip. With the therapist, Sasha will brainstorm and discuss appropriate reactions to being
touched, then make a comic strip depicting herself reacting appropriately when this happens. Next,
the therapist and Sasha will discuss what types of transitions make Sasha uncomfortable and why.
They will work together to brainstorm ways to make these difficult transitions easier and create a
social story Sasha can reference when she knows a transition is coming. This process was started by
adding atypical school events to her calendar so that she is aware of them, and will not be caught off
guard. As much as possible, Sasha will be asked to generate ideas with the therapist making
suggestions as needed. These stories will be put in the back half of her planning notebook so that
they will readily accessible for reference.
From the 4QL FOR- “If the therapist uses additional facilitator-initiated methods like higher order
questions, feedback, physical prompts, lack of verbal prompts, and thinking aloud modeling, then the
child will be encouraged to make decisions regarding the task (Kramer & Hinojosa, 2010).” This
postulate was used because it supports the idea of having Sasha brainstorm her own solutions. The
therapist will guide her decision making process by asking higher order questions and give feedback.
From the Social Participation Model- “If a child can understand and execute rudimentary social skills
needed to play with their peers, the number of positive peer encounters they have will increase and
this may have the potential to widen their interests and skills in other areas. (Kramer & Hinojosa,
2010, p. 327-329).” It is important that we address social skill activities that are being impacted by
Sasha’s sensory dysfunction. She needs to understand why lashing out and hitting is not acceptable,
and come up with strategies to eliminate these maladaptive responses to touch.
-set up: Sasha will sit with the therapist at a table in therapy room. The paper with a comic strip
template and colored pencils will be available.
-Name of activity: Social Stories
-Ways to grade up: Have Sasha write and draw everything herself, have her use a computer program
to create the comic, have Sasha role-play adaptive responses she came up with.
-Ways to grade down: The therapist will suggest strategies if Sasha is unable to suggest viable
options, the therapist will draw/write the story, instead of tackling both reaction to touch and
transitions, we could just do one story.
-Materials: Paper, three hole punch, colored pencils, template for comic strip
Wrap Up 5 minutes: Sasha will be led through a series of yoga poses which is meant to increase
mindfulness. This activity is meant to be fun, calming, and to teach Sasha some poses she can use
when she is feeling out of control. She will be encouraged to practice what she learns at home.
Additionally, yoga will help Sasha develop core strength which is instrumental for handwriting and
other fine motor tasks that need core stability to facilitate distal control. Yoga will also help improve
her balance.
39
From Sensory Integration “If the child’s sensory modulation is brought to an optimal level, the child
will be better able to address problems in foundational abilities and outcomes (Schaaf et al., 2010, p.
106).” Yoga has been found to be an effective intervention for decreasing aggression, and increasing
emotional regulation.
From PEO “Change in person, environment or occupation, or their transaction, can improve
occupational performance.” By providing interventions that help Sasha engage in mindful behavior,
she can change her maladaptive responses which will allow her to improve her occupational
performance at school.
-set up: Sasha will start by standing on a yoga mat in the therapy room. The area will be cleared of
clutter. The therapist will either lead Sasha through yoga poses, or play a short children’s yoga video
like this one. https://www.youtube.com/watch?v=SKIyCBqK2oY
-Name of activity: Yoga
-Ways to grade up: Provide more difficult poses, have Sasha hold poses for a longer period of time,
increase the focus on breathing, discuss how mindfulness can help her
-Ways to grade down: Provide easier poses, hold poses for a shorter amount of time
-Materials: Yoga mat, yoga video
Setting Activity Demands: (Table 7) Anticipated outcome( what

skills you expect to observe
change in based on your
session):
Activity demands of warm up: Outcome of warm up: Sasha
All Relevance and Importance to client-Sasha likes this will improve her focus and be
intervention activity. able to remain emotionally
will take regulated and engaged for the
place in the Objects used and their properties-The scooter is rest of the session. Inattention
therapy used as a support to occupational performance by will be prevented for the rest of
room at the being a regulating and preferred activity. the session by taking the time
school. to help Sasha become regulated
Space demands- the room needs to be large and focused.
enough to set up an obstacle course in, and ride
through it safely. Outcome of main activity:
Sasha’s interactions with her
Sequencing and Timing- Sasha will have to time her peers will improve because she
arm movements in order to propel herself safely will identify and implement
without running her fingers or hands over with the strategies that will prevent her
scooter. from lashing out. Additionally,
she will find more adaptive
Required body functions-Sasha will rely on a variety strategies to help her transition
of cognitive functions in order to propel the so that she is less likely to react
scooter, gage distances, and modulate speed. to transitions in a way that is
not socially acceptable. By
Required body structures-Sasha has all the addressing these concerns, her
structures required to participate in this activity. quality of life will improve
because she will be able to
Activity demands of the main activity: participate more fully in
activities at school. Her
participation will increase as
40
Relevance and importance to client- Sasha and her well as her role competence as
mother desire positive peer interactions and a student and friend.
positive transitions.
Outcome of wrap up: Sasha
Objects used and their properties- colored pencils will improve her emotional
and paper will be used to complete this activity. regulation and decrease her
feelings of aggression by
Space demands- In order to focus, Sasha needs a participating in yoga.
clutter free, distraction free environment to work Additionally, her balance and
in. core strength will improve. This
will lend support to handwriting
Social demands-this activity helps Sasha describe activities as well as playground
and properly react in social situations that she is games where fine and gross
currently not currently successful at. motor control are needed.
Sequencing and timing- this activity needs to be

completed in a specific order for the outcome to be
useful.
Required actions and performance skills- Sasha will

determine what actions are required in certain
situations, and what her reaction should be in
others.
Required body functions- Sasha is capable of the

functions including cognitive level to compete this
activity.
Required body structures- Sasha has the required

structures needed to complete this activity.
Activity demands of the wrap up:

Relevance and importance to client- this yoga
activity will provide Sasha with a tool to use to help
decrease her anxiety regarding transitions, increase
her emotional regulation and decrease aggression.
Objects used and their properties-for this session,

Sasha will use a yoga mat. Future sessions may
include other materials such as a yoga block.
Space demands- Sasha needs a relatively large,

clutter free space to practice yoga in.
Social demands- practicing yoga will help decrease

anxiety, and improve emotional regulation. Both
factors will help Sasha meet the social demands
required of her as a student, friend, and daughter.
41
Performance skills- Knowing how to move her body

to get into poses.
Required body functions- some cognitive problem

solving is needed to decide how to get into
different poses, especially those that may be more
difficult.
Required body structures-Sasha has the body

structures needed for this activity.
Intervention Approach (Table 8 of OTPF): Intervention Type (Table 6 of OTPF):

Intervention approach for warm up: Intervention type of the warm up:
Establish/restore- the prone scooter helps the Activity- playing in a prone position where there
client establish focus for the rest of the session. is significant pressure through large joints helps
Sasha be more engaged in her therapy session.
Prevent-this activity will prevent the client from
losing interest in therapy and prevent her from Preparatory Task-This activity helps Sasha
losing focus early in the session. prepare for the rest of her session.
Intervention approach for the main activity: Education-Using the scooter helps Sasha be more
Establish/restore- this activity will help establish engaged in school related tasks by helping her be
healthy reactions to a variety of situations. more regulated and attentive.
Modify- it is possible that Sasha will come up with Intervention type of the main activity:
ways she can modify either her routine or Activity- creating a social story is a fun and
environment to make transitions easier for her. engaging way for Sasha to address her needs.
Prevent- prevent social isolation that may occur if Education- Sasha will learn appropriate responses
Sasha continues to get into physical altercations to unexpected touch as well as ways to ease
with other students and children in the transitions.
neighborhood.
Self-advocacy- Sasha will begin to identify and
Intervention approach for the wrap up: reflect on what is causing her dysfunctional
Create/promote-Yoga is a tool provided to Sasha reactions. She can take this a step further by
to use for calming, emotional regulation, and talking with teachers and other adults in her life
decreasing anxiety. to help them understand what’s going on, and to
have them help with adaptations and
Establish-this intervention will help establish modifications as needed.
functional reactions to stressful situations.
Intervention type of the wrap up:
Prevent- by reducing aggression, Sasha will Education-Sasha was taught yoga poses that she
prevent the social isolation that may come from can use to improve her reactions to
hitting and lashing out at peers. uncomfortable transitions and unexpected touch.
Practice Model(s):
42
Practice Model used for the warm up: The Sensory Integration FOR was used because outcomes of
this model include “self-regulation to regulate and maintain an arousal level and or an activity level
needed to appropriately attend and focus on the task or activity; maintaining postural control
including muscle tone, strength and balance, ocular control, and bilateral coordination and laterality;
adequate praxis; and development of self-esteem and self-efficacy” (Schaaf et al., 2010, p. 126) The
main reason for this model was to increase Sasha’s focus and attention to the rest of the session,
however, she has some postural concerns (flops over on her desk and is clumsy) that can also be
improved with this activity which will also build core strength and stability. Praxis is addressed
through the problem solving process required to navigate an obstacle course while judging speed and
distance so she does not bump into other objects or the wall. Through trial and error, Sasha will
become successful at this activity which will help improve her self-esteem and self-efficacy.
Practice Model used for the main activity: Supporting models used for the main activity include the
Social Participation Model, the 4QL model, and the Sensory Integration Model. A broad model used
for this activity was Occupational Adaptation (OA). The Social Participation model was used because
the overarching goal of the model is to help youth form organized patterns of behavior that allow for
better participation. By helping Sasha form more organized reactions to being touched, and to
transitions, she will be able to participate better. The 4QL model was used because it provides a
specific and effective technique to use to teach Sasha the skills she needs to learn. The Sensory
Integration model looks at successful participation through self-regulation and the ability to modulate
sensory information. This activity will help Sasha identify ways to self-regulate and modulate sensory
information so she is able to participate in a more functional way at school. OA looks at increasing
adaptability as well and self-evaluation. Sasha is being asked to find ways to generate more adaptive
responses to situations that are distressing to her and self-evaluate what may be causing her distress.
Practice Model used for the wrap up: Sensory integration was used again due to its focus on
successful participation through sensory modulation and self-regulation. Yoga is an intervention tool
that can be used to improve self-regulation especially in regards to being touched unexpectedly
where Sasha is known to lash out.
PEO was used because Sasha is not currently feeling congruence between herself, her occupations,
and her environment. Her beliefs about her environment and her ability to participate in her daily
occupations is effecting her performance. Yoga may be a tool to use to help increase her satisfaction
in performing better at school and socially. Right now, two of her main occupations are participation
in formal education and social participation. If we can find activities that help her do those more
effectively, there will be more congruence between her, her environment and her occupations.
Rationale & evidentiary Support:

Rationale and evidence for the warm up: Per Schaaf, Hunt, and Benevides (2013), using a sensory
integration approach in therapy helps improve participation at home, school, and in family activities
in children with autism. This study showed improvement in participation using parent-rated goal
attainment scales. Though Sasha’s diagnosis is unknown, she struggles with sensory concerns as well
as attention difficulties. This article supports the use of a variety of sensory integration techniques to
regulate children in order to increase their participation.
Rationale and evidence for the main activity: McGill, Baker, and Busse (2015) completed a meta-
analysis on social stories as an intervention approach to teach social skills and to reduce problematic
behaviors. More than 59% of the participants in the study were aged six to 12 which is that age range
Sasha falls into. Overall, interventions showed “small to large decreases in target problem behaviors
43
of children and adolescents with ASD.” Though Sasha does not have a formal diagnosis, she has social
skill deficits and problematic behaviors that can be addressed through social stories.
Rationale and evidence used for the wrap up: According to a poster presented by Fauber, Jansen,
Wenos, and Peachey (2017), “a modified, brief school-based yoga intervention may give students the
ability to enhance their sense of belonging and decrease disruptive behaviors in the classroom.” They
also found that increasing self-awareness through yoga may improve cognitive functioning. Another
finding was that aggression decreased from the baseline to midpoint of their intervention which is still
on-going.
7. Review the Plan
a. Explain how & when you Using a Goal Attainment Scale, Sasha will be re-assessed quarterly to
will review/re-evaluate your determine if modifications need to be made to her goals and what
plan. her progress is. If necessary, we will change her goals based on her
performance at that time. We will also be able to see progress in her
distal outcomes after each treatment session. The therapist will want
to make sure the Sasha’s mother and teacher are aware of her
progress and any changes.
b. Modifications to plan (Are Modifications to the plan will be implemented when she is assessed
they needed? How do you quarterly. If it is found that something is too easy or difficult, goals
implement them?) may be re-written to ensure appropriate progress will be made.
Additionally, small modifications can be made during each session by
grading activities up or down.
c. Continuation/DC from At the end of the school year, if she has met her goals, she will be
Services released from OT services. If she has not, she will continue to receive
services for another year, but goals may be changed, or re-formatted
to make them more appropriate. Additionally, Maria may be
discharged if there is a lack of progress towards her goals or a lack of
compliance.
44
References
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Diagnostic and Statistical Manual of Mental Disorders (5th ed: DSM-5; American Psychiatric
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Fauber, H., Jansen, S., Wenos, J., & Peachery, A. (2017). Exploring the efficacy of a modified school-
based yoga intervention on aggression and emotional regulation in children. American Journal
of Occupational Therapy, (71), doi:10.5014/ajot.2017.71S1-PO5141
Greber, c., Ziviani, J., & Rodger, S. (2007). The four-quadrant model of facilitated learning (part 1): using
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31-39. doi:10.1111/j.1440-1630.2007.00662.x
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Hinojosa (Eds.), Frames of reference for pediatric occupational therapy (3rd ed., pp.306-348).
Philadelphia, PA: Lippincott Williams & Wilkins.
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Hoza, B., Mrug, S., Gerdes, A. C., Bukowski, W. M., Kraemer, H. S., Wigal, T., & Arnold, L. E.
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Deficit/Hyperactivity Disorder? Journal of Consulting and Clinical Psychology, 73, 411-423.
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47

Artifact 7 Pediatric Case Study

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Artifact 7 Pediatric Case Study

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OCTH 6140 - Integrative Case Study #3 Name: ____Tambra Rasmussen__________________________

1. Attention Deficit Hyperactivity Disorder (ADHD): According to understood.org, a

• “Often loses things necessary for tasks or activities.”

Diagnosis: __ Attention Deficit Hyperactivity Disorder ____________________________

List four specific occupations that may be affected for Sasha:

1. __Participation in formal education______________________

4. __IADL’s such as shopping, cooking and cleaning__________

Symptoms. (2013). Retrieved November, 7, 2017 from

Area of Occupation Developmental Expectation

Activities of Daily Living -Bathing/showering independently, at this age, the

-Dressing independently, at this age, a child is able to

-Meal Prep/Cleanup, can make a basic cold meal, and

Additionally, per our Case-Smith text book, page 466,

Leisure -Can identify and participate in a variety of leisure

2. Preparation for Evaluation

“Often fails to give close attention to details or makes careless

Due to inattention, Sasha may make mistakes or miss details in

Attention Deficit Hyperactivity Disorder. (n.d.) Retrieved November

Loe, I.M., & Fledman, H.M. (2007). Educational and academic

According to Hoza et al. (2005) “more than half of children with

Wigal, T., & Arnold, L. E. (2005). What aspects of peer

Per Sourciss, Mainsonneuve, and Normand (2015), children with

Sourciss, M. M., Maisonneuve, M., & Normand, S. (Winter 2015).

Impact on Sasha’s occupational performance at home:

Impact of occupational performance problems on school experience:

Impact on Sasha’s occupational performance at home:

Impact of occupational performance problems on school experience:

Occupations Client Factors Performance Performance Context &

ADLs Values Motor Skills Habits

IADLs Beliefs Cultural

Education Body Functions Process Skills Physical

Leisure Body Social Roles Temporal

a) Practice Models Guiding your Evaluation & Assessment

are regarding social participation. This

b) Obtaining Occupational Profile

Strategy/Assessment Information you would hope to Practice Model & Rationale

to observe her classroom

Sensory Section Classification

Auditory processing More than others

Visual processing Just like the majority of others

Touch processing More than others

Movement processing Just like the majority of others

Body position processing Much more than others

Oral sensory processing Just like the majority of others

Behavior Section Classification

Conduct associated with sensory processing Much more than others

Social emotional responses associated with More than others

Potential Limitations or Barriers

Client Factors (Table 2 of Attention- Sasha is easily Temperament and personality-

Inquires- Even with a student that accidentally bumped

Performance Patterns Person/Routines -Sasha does Person/Roles- Sasha does not

Contextual/Environmental Physical Environment- Sasha is Cultural Context- The school setting is

move on to a new activity in the participating with her peers at recess,

achievement may improve

Potential Strengths or Supports

Social Environment- The school

the supplies necessary to Her ability to play with other children

Required body functions- It Object’s used and their properties-

Occupational Prevention Health & Quality of Life Participation Well-being

-Sasha will -By addressing - By -By improving -By helping -By

5. Intervention Process: Develop a Plan

2. Improving her tolerance of changes in routines, and during transitions.

3. Improving social interactions with peers.

OCTH 6140 - Integrative Case Study #3 Name: Tambra Rasmussen______________________

Diagnosis: Attention Deficit Hyperactivity Disorder __________________________

1. Participation in formal education____________________

4. IADL’s such as shopping, cooking and cleaning________