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Running head: ANGELMAN SYNDROME

Angelman Syndrome: A Case Study About Sue Jillian Battson, Jerold Garrett, Nicole Quisao, Victoria Pringels, James Stewart, Michael Yu OCCT 520

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Occupational Performance Sue is a 12-year old girl with Angelman Syndrome who lives at home with her family. She has seven siblings, but only five currently live at home. Sue participates in a self-contained classroom for behavioral and learning purposes at her neighborhood middle school. She rides the school bus daily and receives physical therapy, occupational therapy, and speech therapy each week for 20 minutes per visit during school. Sues daily performance is impacted by poor coordination, balance, and postural stability. She walks independently with supervision and utilizes a wheelchair during community outings. Sue is nonverbal and communicates with recognizable grunts and selected Sign Language. She has low muscle tone around her oral cavity which results in constant drooling and poor oral motor control. Motorically, Sue functions at the level as a three- or four-year-old and cognitively at the level of an eight-year-old. As a characteristic of Angelman Syndrome, Sue has a very happy demeanor and laughs and smiles often (Clayton-Smith, 1993). Activities of Daily Living Sue requires moderate to maximal assistance in order to complete her daily morning routine. When she wakes up in the morning, a family member helps her to ambulate to the bathroom in order to shower. She is able to undress herself, but requires moderate assistance to don clothing due to a lack of proper balance and postural stability. Sue strives to increase her independence and on occasion can pull up her pants if initially prompted. Additionally, she can periodically put her socks and shoes on. Sue is dependent in toileting and remains in diapers during the day and throughout the night. Sue eats dinner at home with her family nightly and also participates in mealtime at school. Sue can self-feed independently with her hands, but due to her

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poor oral motor skills, she can be very messy. In addition, Sues low tone in her oral muscles contributes to her constant drooling throughout the day. Instrumental Activities of Daily Living Sue is required to help clean up the messes she makes when playing with her toys at home. However, she is unable to complete this task without assistance. Sue is also required to clean and wash her own dishes to the best of her ability, with the exception of glass dishes. As previously discussed, Sue is nonverbal but can communicate with selected Sign Language. Sue also responds to yes or no questions with distinguishable grunts. Sue utilizes a wheelchair around the community for safety purposes as she often runs away. Within her home, Sue can walk independently, but needs constant supervision to ensure safety. Play Sue enjoys playing with her five siblings who live with her. Sue spends the majority of her free time playing with her family and extended family. Sue generally does not play well with other children and requires supervision when interacting with peers outside of her family. Additionally, Sue loves bouncing on the trampoline and playing in water. She enjoys playing with hard, plastic toys that incorporate lights and noises. Sue also enjoys swinging, but requires a time limit to prevent excessive vestibular input. Leisure As previously mentioned, Sue enjoys water and swimming, but does not have the needed coordination and requires supervision while playing on wet surfaces. Sues family often takes her to the library after school to read books. Sue attends weekly church services with her family and is unable to participate in the planned social outings. The church coordinates a bowling night for the youth group and Sue desires to eventually participate in this activity with her peers.

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Social Participation Sue successfully interacts with her siblings and parents at home. In the school setting, Sue is unable to appropriately interact with peers, and is placed in a self-contained classroom throughout the school day. Sue is easily over stimulated by excessive amounts of noise and activity. She often has tantrums and experiences difficulty cooperating with peers. She can only be calmed down by her 20-year old brother. Education Sue attends an inclusive school which includes individuals with disabilities. Sues teacher allows her to eat breakfast in the classroom because it is her favorite activity of the day. Throughout the day, she attends a self-contained classroom because she does not function well in large groups and needs a quieter environment to learn successfully. As part of her weekly schedule, she receives therapy services at school, each visit lasting twenty minutes long. Rest/Sleep Sue enjoys the short drive home from school because it helps her calm down from her busy day. In order to further calm down, she watches a movie in her room once she gets home. Sue plays before and after dinner and goes to bed at seven. Her sleep routine includes: getting her diaper changed, changing into pajamas, brushing her teeth, and watching an episode of Dora the Explorer. Additionally, Sue takes medication in order to help her sleep throughout the night. Sue shares a bedroom with her eight-year old sister which is near her parents bedroom. Movement, Postural Reactions, and Reflexes Movement Sue is able to walk unassisted, but uses a wheelchair during community outings to prevent her from running away. Her muscles are strong and fully developed; she has the strength

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to perform gross motor movements but lacks appropriate balance and postural stability to perform coordinating movements. She can occasionally perform fine motor movements such as buttoning her shirt or putting on socks, but she lacks the bilateral coordination necessary to pull up her pants. Due to her coordination deficits, she functions motorically at the level of a three- or four-year old. Sue has low muscle tone around her oral cavity resulting in constant drooling, making eating very messy. Postural Reactions Sues impairments impact her balance, postural stability, and coordination resulting in immature postural reactions. However, Sues protective and righting reactions are appropriate for her age. Her major postural deficits include equilibrium and anticipatory reactions. Both areas contribute to difficulties in her daily activities, especially during dressing and play activities. Reflexes The reflexes section does not apply to Sue. Sensory Integration and Self-Regulation Sensory processing abnormalities exist in a majority of individuals with Angelman Syndrome and can cause considerable stress to families (Walz & Baranek, 2006). Sue and her family have similar difficulties. She is easily overstimulated when there is excessive noise or activity. In order to calm down from over stimulation, she has to go to a private space to relax. She has various tactile sensitivities. For example, Sue dislikes the feel of carpet or shaggy rugs and refuses to walk on them. She prefers plastic toys and does not tolerate stuffed animals. Nearly 74% of individuals with Angelman Syndrome experience hand flapping and hyperexcitability (Walz & Baranek, 2006). When Sue becomes overstimulated, she also exhibits hand

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flapping. If she refuses to cooperate in an activity, she can become difficult to handle. Only her older 20-year old brother and her parents are able to calm Sue when she has a tantrum. Sue loves to play in the water. Clarke and Marston (2000) found this characteristic and enjoyment of sensory experiences with water in 67% of their sample population. This is problematic, however, because Sue does not have the needed coordination to swim and requires constant supervision when playing on wet surfaces. Sue enjoys vestibular input, particularly swinging which elicits a calming effect. Walz and Baranek (2006) explain that individuals with Angelman Syndrome have difficulty modulating proprioceptive and vestibular input which results in high rates of sensation-seeking behaviors. Assessments In an outpatient pediatric clinic, four assessments will be used to obtain additional information about Sues functional abilities. Each of the following assessments are ageappropriate and are suitable for her diagnosis. These assessments are either norm-referenced or criterion-referenced and should be used in conjunction with parent report and informal observation. After these evaluations have been administered, the therapist should use clinical reasoning to determine how Sues occupations are impacted. To evaluate Sues motor deficits, the Bruininks-Oseretsky Test of Motor Proficiency, Second Edition (BOT-2) and the Beckman Oral Motor Evaluation Protocol (BOMEP) will be administered. The BOT-2 will assess Sues lack of coordination, balance, and postural stability. The BOMEP will assess specific oral motor skills. The BOMEP will be utilized to evaluate Sues poor eating skills and constant drooling. The therapy team recognizes that the BOMEP should be used only after receiving specific training in administration. Both assessments will provide additional information regarding specific motor skills to be addressed during intervention.

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The Social Skills Rating System (SSRS) will be used to evaluate Sues social participation. Sue lacks social skills and displays behavioral outbursts when interacting with peers. These behaviors are assessed within the SSRS. This assessment will be especially effective in determining which skills Sues parents deem important. Finally, the Childrens Assessment of Participation and Enjoyment and the Preference for Activities of Children (CAPE and PAC) will be utilized to obtain further information regarding Sues participation and preference in activities outside of the mandated school environment. Activities within the CAPE and PAC include Recreational, Physical, Social, Skill-Based, and Self-Improvement. This assessment will determine activities that may be motivating for Sue. The CAPE and PAC will provide feedback for the therapist when planning therapeutic interventions in order to engage and capture Sues preference for specific activities. Functional Problem Statements 1. Sue is unable to participate independently in dressing due to poor motor coordination, balance, and postural stability. 2. Sue is unable to participate in social outings due to auditory and visual hypersensitivity. 3. Sue is unable to transition between play activities due to her inability to manage her emotions. 4. Sue is unable to eat without food and liquid spillage from the oral cavity due to poor oral motor control. 5. Sue is unable to interact with peers due to poor social skills and behavioral outbursts. Family Goals 1. Sue will dress herself independently by pulling up her pants and putting on socks and shoes with minimal verbal cues. 2. Sue will independently clean up her toys with minimal prompting. 3. Sue will successfully interact and function in a large group setting. 4. Sue will eat without creating a mess. 5. Sue will learn rules regarding water safety. Occupational Therapy Goals

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Dressing Goal Sue will independently don her pants, shirt, socks, and shoes as part of her morning routine at least five out of seven days a week by January 15, 2014. Objective one. Sue will don her bathing suit while sitting in a chair with moderate assistance at least five out of seven days a week by June 15, 2013. Stickers on socks. Objective/Purpose: 1. To increase balance, coordination, postural stability, and fine motor skills used in buttoning. 2. To promote appropriate anticipatory and righting reactions. Materials: Socks, Dora stickers, Dora activity sheet, and a chair or therapy ball Directions: 1. Place stickers on the bottom of the sock. 2. Assist Sue to don socks. 3. Instruct/assist Sue to sit on the therapy ball. 4. Have Sue stabilize her body with her right hand and left leg. 5. Have Sue lift her right leg (she can help lift with her right hand) and place right leg onto left leg. 6. While in this position, have Sue use her left hand to peel stickers off of the socks. 7. Have Sue place the sticker on the activity sheet, matching it with the correct picture. 8. Repeat step six until all stickers have been peeled off her socks. 9. Repeat all the above steps, switching to the left leg and peeling the stickers with her right hand. Grading: This activity can be either graded up or down to achieve the just right challenge. Initially, Sue will use a chair to complete this activity. Once Sue has mastered this activity with a chair, various size therapy balls can be introduced. The last step can be graded up by using smaller stickers and graded down the activity by using larger stickers. Using Dora the Explorer stickers and an accompanying Dora the Explorer activity sheet will help to keep this activity motivating and meaningful for Sue. Hula-hoop obstacle course. Objective/Purpose: 1. To increase bilateral coordination, range of motion (ROM), motor planning, balance, and postural stability.

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2. To facilitate the synergy movements required during her morning dressing routine. Materials: Hula-Hoops Directions: 1. Place 10 hula-hoops in a straight line. 2. Instruct/assist Sue to step into the first hula-hoop with both feet. 3. Instruct/assist Sue to bend both of her knees and hips, making sure to use proper body mechanics. 4. Instruct/assist Sue to grab both sides of the hula-hoop and lift it over her head. 5. Instruct/assist Sue to place the hula-hoop off to her side. 6. Repeat the above steps for all hula-hoops. Grading: This activity can be graded up by using multiple hula-hoops or can be graded down by using fewer hula-hoops. Other ways to grade this activity up would include using weighted hulahoops, different diameter hula-hoops, and incorporating a timer to modify speed of the activity. Objective two. Sue will don her pants, shirt, socks, and shoes while standing up with minimal assistance as part of her morning routine at least five out of seven days a week by October 15, 2013. Putting on a bathing suit and life jacket. Objective/Purpose: 1. To promote independence in dressing and fine motor skills. 2. To increase balance and postural stability. Materials: Bathing suit and life jacket Directions: 1. Place bathing suit and life jacket in front of the client. 2. Assist Sue in putting on bathing suit, allowing her to be as independent as possible. 3. Assist Sue in putting on life jacket, allowing her to be as independent as possible. Grading: Dressing activities that require Sue to put on a bathing suit and life jacket is meaningful and can be incorporated before going into the pool. This activity can graded by using a variety of bathing suit sizes and styles. A larger bathing suit size will grade the activity down. In addition, this activity can be graded down by putting the bathing suit on while in a seated position and graded up by putting the bathing suit while standing. Pool clothing obstacle course. Objective/Purpose: 1. To increase balance and postural stability required during dressing. Materials: Swimming pool, life vest, kickboard, flotation mat, and various pieces of clothing Directions: 1. Place clothing into two separate piles at opposite ends of the pool.

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Assist Sue to get into the pool. Instruct Sue to use the kickboard to get to the other side of the pool. Instruct Sue to grab an article of clothing and put it on. While still wearing clothing, instruct Sue to go to the opposite side of the pool using the flotation mat. 6. After reaching the opposite side of pool, instruct Sue to put on an additional article of clothing. 7. Repeat steps two through six with various articles of clothing and flotation devices. Grading: This activity can be graded up by requiring more clothing to be put on or by making Sue exit and re-enter the pool to retrieve the articles of clothing. This activity can be graded down by requiring less articles of clothing to be put on or handing the articles of clothing to Sue. It can also be graded by using different methods to get across the pool. For example, Sue can lay on a floatation mat and use a paddle to propel. Eating Goal Sue will eat a meal independently using a utensil with minimal food or liquid spillage from the oral cavity at least two out of three meals a day by January 15, 2014. Objective one. Sue will eat a meal independently with minimal food or liquid spillage from the oral cavity at least two out of three meals a day by August 15, 2014. Can do oral motor fun deck cards. Objective/Purpose: 1. To increase oral muscle strength required for eating. Materials: Can Do Oral Motor Fun Deck Cards Directions: 1. Choose cards that target oral motor skills. 2. Instruct Sue to imitate the facial expression displayed on the card. 3. When unable to perform facial expressions independently, provide cues in the order of verbal, visual, and then hands-on. Grading: Cards are graded in difficulty by number. Start with lower numbers for easier tasks and gradually increase to higher number cards. Blowing cotton balls with straws. Objective/Purpose: 1. To increase oral muscle strength and promote lip closure necessary to decrease spillage from the oral cavity. Materials: Cotton balls, straws, and table Directions:

2. 3. 4. 5.

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1. Place a cotton ball at one end of the table. 2. Instruct Sue to pick up straw and place it between her lips. 3. Instruct Sue to blow into the straw and move the cotton ball to the opposite side of the table. 4. Repeat steps 2-4, instructing Sue to blow the cotton ball to specific areas of the table. Grading: This activity can be graded up or down by using different number of cotton balls and different sized straws. Obstacles can also be placed closer or further apart. Objective two. Sue will eat a meal independently using a utensil with moderate food or liquid spillage from the oral cavity at least two out of three meals a day by October 15, 2014. Eating a meal or snack using graded utensils. Objective/Purpose: 1. To increase fine motor skills necessary for independent utensil use. Materials: Adaptive utensils with large grips, utensils with a standard grip, and meal or snack Directions: 1. Place food in front of Sue. 2. Instruct/assist Sue to grip the adaptive utensil appropriately. 3. Instruct/assist Sue to scoop food onto the utensil. 4. Instruct/assist Sue to bring the utensil to her mouth without spilling food 5. Have Sue eat the food. 6. Repeat steps 2-5 until meal is completed. Grading: This activity can be graded up using standard utensils or by introducing new foods that the client is not familiar with. The activity can be graded down by using adaptive utensils with larger grips that are easier for the client to grasp or weighted utensils that allow for better control of the utensil. Food race. Objective/Purpose: 1. To promote utensil use and increase coordinated movements required for utensil use. Materials: Spoon, two bowls, and Mac N Cheese Directions: 1. Place two bowls about 10 ft. apart, one with Mac N Cheese and one without. 2. Instruct/assist Sue with the proper grip for utensil use. 3. Instruct/assist Sue how to scoop the Mac N Cheese out of the bowl with the spoon. 4. Instruct Sue to hold the spoon and get to the other bowl as fast as she can without spilling the Mac N Cheese.

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5. Instruct/assist Sue to place Mac N Cheese into the empty bowl. 6. Repeat steps three to five until the entire Mac N Cheese has been transferred. Grading: This activity can be graded up by having the client go a farther distance while using a spoon with a smaller handle. It can be graded down by having the client travel a shorter distance while using a spoon with a larger handle. Different foods can be placed on the spoon to make it more or less difficult as well. Social Goal Sue will participate in a social outing with peers and adult supervision with minimal verbal cues and without a behavioral outburst two out of three times a week by January 15, 2014. Objective one. Sue will participate in a social activity with at least four other individuals with minimal verbal cues and without behavioral outburst once a week by April 15, 2014. Social stories. Objective/Purpose: 1. To teach social skills and enhance social participation. 2. To explain social norms. Materials: Social Stories Directions: 1. Create a Social Story about Pool Safety. a. The story should be easily understood by the child. b. Include descriptive sentences (The pool is deep), perspective sentences (I like swimming), and directive sentences (I should walk slowly). c. Use 3-5 descriptive and perspective sentences for every directive sentence. d. Each page should include one sentence and one real-life picture for that sentence. e. Refer to the following website for more information: http://www.thegraycenter.org/social-stories 2. Read the Social Story with Sue. 3. Talk about pool safety with Sue. 4. Go to the therapy pool and practice pool safety. 5. Follow steps 1-4 to teach social interaction skills (initiating conversations, turn taking, etc.) and as an introduction to the water aerobics class (highlighting sensory stimulation, appropriate behavior during class, and safety). Video modeling for a water aerobics class. Objective/Purpose:

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1. To provide social skills practice and increase social participation. Materials: Video camera Directions: 1. Have Sue participate in a water aerobics class. 2. Gain permission to film one of the peers in the class. 3. Film the peer listening to the instructor and following directions. 4. Edit the film as needed. 5. Watch the film with Sue prior to the next water aerobics class. 6. Discuss how the peer listened to and followed directions. 7. Have Sue practice listening to and following directions. 8. Provide a reinforcement (e.g. ten minutes of free time in the pool) if Sue listens and follows directions during the next class. 9. Repeat steps 1-8 for other appropriate social behaviors. Objective two. Sue will tolerate an active social environment with various noises and lighting with adult supervision and less than two behavioral outbursts by August 15, 2013. Self-awareness training program. Objective/Purpose: 1. To teach self-awareness and regulate behavior when over aroused. Materials: Pictures of the stimuli that make Sue anxious and over aroused and pictures of people showing physical symptoms when anxious Directions as provided by Scott Bellini (2006): 1 Response Description: a Show Sue pictures of people showing physical symptoms when anxious. b Discuss and describe with Sue the physical symptoms she feels when she becomes anxious and over aroused. 2 Response Detection: a Discuss and describe with Sue the stimuli that make her anxious and over aroused. b Show Sue pictures of the stimuli that makes her anxious and over aroused. 3 Early Warning: a Discuss and describe with Sue the order in which physical symptoms occur (e.g. heart starts racing, then hands start flapping, then head starts spinning). b Show Sue pictures of the physical symptoms and have her place them in the correct order. c Teach Sue to use deep breathing when she begins to feel the first signs of being anxious. d Practice deep breathing for ten minutes at each therapy session.

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4 Situation Awareness Training: a Discuss and describe with Sue the environments that evoke anxious behavior. b Teach Sue to use deep breathing before encountering such environments. Bowling. Objective/Purpose: 1. To tolerate loud noises, crowded areas, bright lights, and reinforce social skills. Materials: Bowling equipment and music Directions: 1. Teach Sue the rules of bowling. 2. Have Sue participate in a swinging activity in order to calm and organize her sensory system. 3. Set up bowling in the therapy room. 4. Begin a game of bowling with Sue. 5. Gradually incorporate various noises (e.g. music) and various lighting (e.g. dim lights, lights turned on all the way) throughout the bowling session. 6. Remind Sue to use relaxation techniques if she becomes over aroused. 7. As Sue begins to tolerate the sensory stimuli, have peers participate in the bowling activity with Sue. 8. When prepared, have Sue play a game at a real bowling alley with her church youth group. Treatment Plan Environmental Setting Sue will attend therapy services at an outpatient pediatric clinic. This clinic has a therapy pool, sensory gym, kitchen, individual treatment rooms, an outside playground, and many easily accessible community resources. Each therapy room has an observation window for parent education and observation purposes. This clinic promotes occupation-based practice and mimics a childs natural environment. SOAP Note S: Client communicated with grunts and simple sign language when cued to participate. Client was initially anxious upon entering the clinic. Client began to interact and smile after becoming acquainted with the unfamiliar environment.

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O: Client participated in 60-minute OT tx session in an outpatient therapy clinic to focus on improving trunk stability, balance and coordination, and oral motor control for increased engagement in functional activities. Client used immature oral motor control when pursing lips to imitate CanDo facial expressions. Client demonstrated low muscle tone to form appropriate lip positioning during imitation. Client consistently drooled when engaging in oral motor activity. Client fatigued before the oral motor activity was completed. When seated in a chair, client I supported self with L trunk flexion and L hand stabilization during bilateral LE activity. When prompted to retrieve Dora the Explorer stickers from bottom of sock on L heel, client initiated hip internal rotation and knee flexion. Client demonstrated loss of balance and incoordination when reaching towards heel and when placing sticker onto activity sheet. Client received mod A for trunk and hip control and mod verbal prompts to retrieve and match stickers onto activity sheet. A: Limited oral motor control and low muscle tone limits clients ability to engage in developmentally appropriate activities and impedes meal participation. Client continues to demonstrate poor trunk stability, balance and coordination, and lack of ability to use appropriate stabilization techniques, which limits clients ability to engage in age-appropriate dressing activities. Ability to initiate lip pursing during oral motor activity shows progress in decreasing food and liquid spillage from the oral cavity. Ability to perform trunk co-contraction after verbal prompts and HOH facilitation shows progress in trunk stability and balance and coordination. Initiation of oral muscles to participate in activity shows potential for functional meal participation. Clients ability to complete balance and coordination activity with mod A shows potential to increase I in dressing. P: Client will continue 60-minute OT tx sessions 2x/wk for 5 months to increase I in trunk stability, balance and coordination, and decrease oral cavity spillage. Treatment plan will address balance and stability to increase participation in developmentally appropriate and meaningful occupations. Treatment plan will also begin to incorporate graded oral motor activities to facilitate clients ability to properly engage in meal participation. Will discuss appropriate activities with family to complete during home-based program. Discharge Environment Sue attends therapy services at an outpatient clinic and does not require a post-discharge plan. She will continue to receive services at the outpatient clinic and during school until intervention and family goals are achieved. Recommendations

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We recommend that the family implement deep breathing exercises into Sues daily routine, especially before activities of high arousal. We recommend that the family read Social Stories with Sue prior to participating in activities with peers. We recommend that the family play oral motor games (e.g. cotton ball races with a straw or CanDo imitation cards) to strengthen Sues oral muscles. We recommend that the family perform oral motor massages with Sue prior to mealtime, in order to activate Sues oral muscles. We recommend that the family provide opportunities for Sue to dress independently during her morning routine. We recommend that the family strive to include Sue in age appropriate activities. Evidence Justification Sue displays excessive drooling and messy self-feeding as a result of low muscle tone in and around her oral cavity. Disruptions in feeding and swallowing may result in increased caregiver burden, social restriction, and a diminished quality of life (Arvedson, Clark, Lazarus, Schooliong, & Frymark, 2010). Oral motor exercises (OME) are often incorporated into treatment plans for children with feeding and swallowing complications (Longemann, 2000). OMEs are widely used by clinicians; however, the research on the effectiveness of these exercises is highly controversial. As Arvedson and colleagues (2010) discussed in their systematic review, the lack of standardized measures to assess OMEs among children is a major factor contributing to this debate. Occupational therapists should use clinical reasoning and judgment when generalizing research findings for each childs specific condition. It is assumed that in Sues circumstance, OMEs would be an effective intervention.

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Sue lacks coordination and balance in order to perform her morning dressing routine. Aquatic therapy is seen as a means to addresses these deficits, while also being intrinsically motivating to Sue. Getz, Hutzler, and Vermeer (2005) conducted a systematic review of literature regarding the effects of aquatic intervention in children with neuromotor impairments. Therapy conducted in water enables smooth movements for children who often struggle initiating these movements on land by minimizing the gravitational stress on the body. The findings concluded that hydrotherapy was a beneficial intervention for children with neuromotor impairments. Some potential benefits of therapy included improvements in walking balance, environmental interactions, and decreases in hyperactive behaviors (Getz, Hutxler, & Vermeer, 2005). Sue would benefit from similar results in order to increase her dressing skills. Social Stories have been proven effective in teaching social skills to children with autism spectrum disorders (ASD) (Scattone, Tingstrom, & Wilczynski, 2006), but lacks support for its use with populations outside of the ASD. However, ASDs are characterized by deficits in social skills. Therefore, it can be assumed that any social interventions that are effective for those with ASD will also be effective for those with similar social skill deficits. Sue displays inappropriate social behavior and lacks social interaction skills and would therefore benefit from interventions utilizing Social Stories.

References Arvedson, J., Clark, H., Lazarus, C., Schooling, T., & Frymark, T. (2010). The effects of

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oral motor exercises on swallowing in children: an evidence-based systematic review. Developmental Medicine & Child Neurology, 1000-1013. Bellini, S. (2006). Building social relationships: A systematic approach to teaching social interaction skills to children and adolescents with autism spectrum disorders and other social difficulties. Shawnee Mission, KS: Autism Asperger Publishing Co. Clarke, D. J., & Marston, G. (2000). Problem behaviors associated with 15q- Angelman syndrome. American Journal on Mental Retardation, 105, 25-31. Getz, M., Hutzler, Y., & Vermeer, A. (2005). Effects of aquatic interventions in children with neuromotor impairments: A systematic review of the literature. Clinical Rehabilitation, 20, 927-936. Pearson Education, Inc. (2012a). Clinical Assessment. In Bruininks-Oseretsky Test of Motor Proficiency, Second Edition (BOT-2). Retrieved from http://www.pearsonassessments. com/HAIWEB/Cultures/enus/Productdetail.htm?Pid=PAa58000 Pearson Education, Inc. (2012b). Clinical Assessment. In Childrens Assessment of Participation and Enjoyment (CAPE) and Preferences for Activities of Children (PAC). Retrieved from http://www.pearsonassessments.com/HAIWEB/Cultures/en-us/Productdetail.htm?Pid =076-1606-432&Mode=summary Scattone, D., Tingstrom, D. H., & Wilczynski, S. M. (2006). Increasing appropriate social interactions of children with Autism Spectrum Disorders using Social Stories. Focus on Autism and Other Developmental Disabilities 21(4) 211-222. doi: 10.1177/10883576060210040201 Walz, N.C., & Baranek, G. T. (2006). Sensory processing patterns in persons with Angelman syndrome. American Journal of Occupational Therapy, 60(4), 472-479.