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Stephanie P. OTR

Case Study: Amelia

This page provides an example of the occupational therapy process as I would apply it to practice. 

Using the case of Amelia, located in my Occupational Therapy for Children and Adolescents (Case-Smith, 201, p. 658) textbook I will develop a case study. The case study will include Amelia’s;

  • Occupational profile
  • My recommended evaluation and intervention plan
  • Factors expected to influence Amelia’s progress
  • Any evidence that informed my clinical-reasoning.

Criteria

Case study presentation

B.4.1:PD, EIP

A PDF printable format of this page, is located on the PDF page of this website.

Meet Amelia

Amelia’s background as it is published reads:

Amelia is a 24-month old child referred to an early intervention program by her pediatrician because of concerns with gross and fine motor development, feeding, and suspected sensory processing problems. Amelia cries often in a distressful manner. Problem areas for Amelia as reported by her mother, include uncooperative behaviors, “extreme melt-downs,” whining and fussing, feeding problems associated with aversion to food textures, fearfulness, and poor balance. Although she sat independently at 6 months of age, she did not reach for and grasp an object until 8 months of age. She rolled from back to stomach at 9 months of age and began crawling at 11 months. (Case-Smith, 2015, p. 658)

 

 

 

Photo credit: Cynthia Abbot Photography, Location: Upstairs on the Square, Cambridge, MA, Date: 8/28/2010

 

 

Occupational Therapy Process

       Chapter 24 of the Willard and Spackman textbook illustrates a map that occupational therapy practitioners can use to help guide their practice from evaluation to outcome. 

(Schell, 2015, p. 267)

Occupational Therapy Profile

            Case-Smith et al. (2015) describes the content and purpose of an occupational profile to be the child’s “occupational therapy history, experiences, patterns of daily living, interests, values, and needs. It is designed to gain an understanding of the client’s perspective and background” (p. 501). Based on the background information provided for Amelia her occupational profile is as follows:

            Amelia is 24-month old female who was referred for occupational therapy services by her pediatrician. Per pediatrician report, Amelia presents with developmental delays in the areas of gross and fine motor development and feeding. Amelia’s pediatrician also reported concern over Amelia’s sensory processing. Amelia’s mother reported that Amelia cries in a distressful manner. Amelia’s mother also reported the following areas of difficulty; uncooperative behaviors, “extreme melt-downs,” whining and fussing, feeding problems associated with aversion to food textures, fearfulness, and poor balance. Amelia reportedly; sat independently at 6 months of age, began to reach and grasp for objects at 8 months of age, rolled from back to stomach at 9 months of age, and began crawling at 11 months. 

Analysis of Occupational Performance

The data used to develop an analysis of Amelia's occupational performance will be collected using the following tools:

Evaluation Instrument(s) Used:

  • Sensory Profile --- “measures response to routine sensation across the following eight categories: auditory, visual, taste/smell, movement, body position, touch, activity level, and emotional/social.” (Schell, 2015, p. 840) 
  • The Peabody Developmental Motor Scales — 2 --- designed to be used for individuals from birth to 7 years. It quantitatively assesses motor development of children with a focus on gross and fine motor skills. (Schell, 2015, p. 1217)

Other Assessment/Evaluation Input:

  • Parent/Caregiver Report
  • Clinical Observation 

These instruments were selected based on the reported history documented in Amelia’s referral. 

Evidence-base

Frame of ReferenceFocusFunction/DysfunctionMotivation/ChangeInterventionAmelia's Area of Focus
DevelopmentalAges & StagesStage of lifeMastery of age-appropriate life tasksLife tasksMotor development
Sensory IntegrationSensory developmentAge-appropriate sensory integrationRegulation of sensory inputUse of equipment to give sensory inputSensory processing

 

Modified from (Cole, 2008, p. 283)

 

Intervention Plan

  • Weekly treatment sessions 
  • Activity: While wearing a weighted-vest (Case-Smith, 2014, p. 290) Amelia will dress and feed her baby doll. Amelia will also make pretend food with play-doh. 
  • Uses of pretend play to participate in life skills training
  • Use of sensory equipment---weighted vest, play-doh, velcro on doll's diaper

 

Factors that May Influence Treatment

Amelia is 24-months old, so a family-centered intervention (Case-smith, 2014, p. 648) approach will be taken for her service delivery. Factor’s that may influence treatment are the family’s life-style, time commitments, and routines. In terms of the Occupational Therapy Practice Framework external domain areas that may influence treatment are Amelia's contexts and environment. 

(Schell, 2019, p. 53)

References

Case-Smith, J., & OBrien, J. C. (2015). Occupational therapy for children and adolescents. St. Louis: Mosby.

Cole, M. B., & Tufano, R. (2008). Applied theories in occupational therapy: A practical approach. Thorofare: SLACK.

Schell, B. A., & Gillen, G. (2019). Willard and Spackmans occupational therapy. Philadelphia: Wolters Kluwer.