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Running head: RUBY: A CASE STUDY OF A SIX-YEAR-OLD GIRL

Ruby: A Case Study of a Six-Year-Old Girl Elisa Dick, Jacques Kriel, Devina Robinson, Breanne Rowland, Michael Yarvi, & Steve Young Touro University Nevada

RUBY: A CASE STUDY OF A SIX-YEAR-OLD GIRL How does this client participate in the 8 occupational areas? Consider the clients age and condition. Ruby is a 6 year old child diagnosed with developmental delay and suspected of having ADHD. The client is experiencing difficulties in almost all of her areas of occupation. ADLs Ruby is able to feed herself independently, however she frequently chokes and needs

reminders to chew. Ruby receives a blended diet at school due to the choking hazard. She is fully independent in undressing but requires assistance in donning her shoes and socks, brushing her hair and teeth, tying her shoes, and washing herself while bathing. She is able to button and unbutton medium sized buttons and is able to zip a zipper. The client has poor safety awareness which limits her ability to do some ADLs without supervision. She also has absent seizures whenever she is extremely fatigued or ill, creating a safety concern, requiring supervision during bathing. IADLs Client has difficulty in communication management due to her writing difficulties and in community mobility due to her fatigue. Rest and Sleep The client has significant sleep problems and she must use medication or she only sleeps 2-3 hours a night. Education Ruby is in a typical class but is frequently in trouble for not paying attention and states that she can't focus. Rubys fine motor difficulties cause substantial problems meeting the activity demands of the educational environment. Ruby has difficulty with writing due to poor

RUBY: A CASE STUDY OF A SIX-YEAR-OLD GIRL grasping patterns which results in fatigue. However, using a gripper does help decrease her fatigue by correcting her grip. Her poor visual discrimination causes her to be unable to write within the lines on a piece of paper; thus, adaptations such as highlighting the line allow her to improve her handwriting because she can see where she is supposed to be writing. Ruby has

difficulty with bimanual coordination as is evidenced by her difficulty with cutting. She also has poor visual memory resulting in her inability to complete many classroom tasks from memory. The client cannot visually track a moving item across midline and has a convergence problem, which leads to difficulty with visual attention in the classroom. She also lacks problem solving strategies, motor skills, and visual perceptual skills to complete things such as puzzles. Work A six-year-old does not typically engage in work; thus, this area of occupation is not applicable. Play Ruby cannot ride a bike without supervision and can only ride on the grass because her seizure disorder causes a safety risk. Furthermore, Rubys fatigue limits her ability to engage in prolonged play with peers. Rubys play is also limited by her constant referencing of her imaginary friend, isolating her from playmates. Leisure Many children her age enjoy reading, drawing, and watching TV for leisure. However, Rubys fatigue, poor visual perceptual skills, and poor fine motor skills interfere with Rubys ability to participate in these leisure activities. Furthermore, many six-year-olds participate in extracurricular activities, but Ruby has difficulty participating in structured leisure activities due to her inattention.

RUBY: A CASE STUDY OF A SIX-YEAR-OLD GIRL

Social participation The clients constant references to her imaginary friends interfere with her ability to make real friends. The client has difficulty focusing at school. Ruby uses her imaginary friend to help her complete tasks. The client gets easily fatigued which interferes in her ability to participate in the gross motor play that is typical of children her age which could isolate her from her peers. Briefly describe the characteristics of movement, postural reactions, and/or reflexes that are of particular importance of this client. Ruby is able to walk independently; however, she has a gait abnormality, being addressed in physical therapy. Client becomes easily fatigued when walking long distances interfering with her ability to participate in the community. Clients fatigue and poor bimanual/bilateral coordination significantly interferes with her occupational performance in all areas of occupation. Briefly describe any sensory integration or self-regulation issues that relevant to this client. The client has significant sensory integration and self-regulation issues that result in difficulty engaging in occupations due to an inability to properly regulate her system or to perceive/process the sensory information in the environment. The client has been found to have definite differences in: sensory seeking, emotionally reactive, low endurance/tone, inattention/distractibility, sensory sensitivity, auditory processing, visual processing, vestibular processing and touch processing. Additionally, sensory processing related to endurance/tone, multi-sensory processing, body position and movement, movement affecting activity level, sensory input affecting emotional responses, visual input affecting emotional responses and

RUBY: A CASE STUDY OF A SIX-YEAR-OLD GIRL activity level, and emotional/social response delays were indicated. The client has also been found to have a probable difference in poor registration and oral sensory processing. The client would not tolerate a visual exam. Furthermore, the client has been found to be delayed in visual discrimination, form constancy, sequential memory, and visual closure. The client has been found to be advanced in visual memory, spatial relation, and figure ground. The client becomes easily fatigued during visual tasks. Ruby also has difficulty in spatial relationships and motor planning when drawing and presents with a one year delay in her drawing ability. What assessment(s) will you use to evaluate this child? Prior assessments were completed in order to identify potential concerns and difficulties in Rubys ability to process sensory information and visual perceptual skills correctly. Rubys

mother completed the Sensory Profile questionnaire to help identify possible concerns regarding the inability to process sensory information. The Test of Visual Perceptual Skills, 3rd edition, specifically measured non-motor visual perceptual skills. Based on the results of these assessments, we thought that feeding was important because of the need of nutrients for the body to function in all motor and cognitive tasks. These results also indicate the most significant cognitive delays in visual discrimination, as well as form constancy, and visual closure-which should be alleviated due to our approaches of an obstacle course and other visual motor tasks that have been recognized in the literature. The Vineland Adaptive Behavior Scales, Second Edition will be used in order to measure Rubys adaptive behavior in different environments. Ruby has many concerns and the test will help determine her strengths and weaknesses, and the amount and types of assistance needed. Due to Rubys difficulties with swallowing and inability to adequately break down food, a modified Barium swallow study is required. Before we can begin working on feeding it is

RUBY: A CASE STUDY OF A SIX-YEAR-OLD GIRL imperative that we know it is safe to do so. A modified barium swallow will give us more information about what types of foods are safe for Ruby to eat. To most efficiently teach the child skills that will help her remediate the delays that she experiences, a form indicating a childs type of learning (Learning4Life) should be determined prior to treatment. This can be done using a test that is typically used for kids her age. It has age appropriate wording and is easy and quick to administer. Ruby is also having reading difficulty

which causes her difficulty meeting educational goals. Because so much information in school is presented visually it would be helpful for Ruby to have information presented to her in her preferred learning style. List five functional problem statements (You can assume some of these based on the information provided in the case study.) 1. Client requires assistance to complete interlocking puzzles due to poor motor planning 2. Client is unable to complete many classroom tasks from memory due to a poor visual memory. 3. Client is unable to write within the lines on a piece of paper due to poor visual discrimination. 4. Client becomes easily fatigued which results in her inability to participate with peers and in the community. 5. Inability to visually track across midline limits clients ability to visually attend in the classroom. 6. Client requires assistance to don her shoes onto the correct feet, don her socks, brush her teeth and hair, tie shoes, and wash her body due to poor bilateral coordination and low muscle tone. List five family/caregiver/child goals 1. Client will eat independently without verbal cues while chewing in order to break down her food properly.

RUBY: A CASE STUDY OF A SIX-YEAR-OLD GIRL 2. Client will participate in group activities for 30 minutes without referencing of imaginary friends 3/5 consecutive days. 3. Client will complete an interlocking puzzle independently 4/5 trials. 4. Client will maintain a seated position at desk for 15 minutes with 2 or fewer verbal cues 4/5 attempts. 5. Client will independently brush her hair and teeth 3/4 attempts. Goals, Objectives, and Activities

Goal 1. Ruby will improve oral motor skills to safely chew and swallow a peanut butter and jelly sandwich with 2 verbal cues or less by 6/22/2013. Objective 1. Ruby will show improved oral motor strength by eating soft fruit safely independently while seated during mealtime by 3/15/2013. Activities: 1. Webber Oral motor practice cards 2. Chew art from cold cuts, cheese slices, and apple slices Objective 2. Ruby will demonstrate safe chewing awareness by playing Foodland, a modified version of Candyland with foods corresponding to each colored space. Activities: 1. Bolus bag to chew different foods and identify how many chews that food needs to be safe to swallow. 2. Organize food cards into difficult, medium, and easy to chew. Goal 2: Ruby will be able to independently select a matching outfit from her closet within a fiveminute time frame by 6/22/ 2013. Objective 1: Ruby will complete an obstacle course including retrieving a ball based on color cue

RUBY: A CASE STUDY OF A SIX-YEAR-OLD GIRL from the ball pit, crawling through the barrel, and throwing the ball in the appropriate colored bucket to work on visual perceptual skills with four verbal cues by 5/20/2013. Activities: 1. Find the stuffed animal from the ball pit. 2. Find the difference between pictures. Objective 2. While seated at the table, Ruby will replicate a 4-6 block pattern made by the therapist using square blocks to work on form constancy independently 3/5 trials by May 1. Activities: 1. Matching worksheet for form constancy. 2. Match wooden shape blocks to corresponding shape cards

Goal 3: Ruby will complete a 6-piece seated at a table to work on staying on task with fine motor activities independently by 5/22/2013. Objective 1: Ruby will work on fine motor skills by forming the letters of her name in Theraputty 3/4 trials while seated at a table with 1 verbal cue by 5/10/2013. Activities: 1. Ruby will create tissue paper art by writing a word of her choice with glitter glue, then placing tissue paper on the glue using training chopsticks. 2. Making paper chains. Objective 2: Ruby will stay on task and work independently to complete a maze seated at the table with auditory distractions by 3/15/13. Activities: 1. Simon Says 2. Skillstreaming Lesson 10 Ignoring Distractions

RUBY: A CASE STUDY OF A SIX-YEAR-OLD GIRL Treatment Plan

Ruby will participate in a one-hour treatment session in an outpatient clinic. The therapist will utilize a client-centered and family-orientated approach to address the needs of Ruby. Various activities were selected to take into account the goals of the family, along with playdriven activities incorporating Rubys interests. The therapist selected tasks that could be transferred to other environments that are also prominent in Rubys life, such as school and home. The overall goals of the treatment plan were devised with the hopes of improving a variety of aspects of Rubys life specifically focusing on feeding skills, attention, and visual perceptual skills. Goal 1: Ruby will complete a 6-piece puzzle in a seated position at the table to work on staying on task with fine motor activities independently by 5/22/2013. Objective 1-: Ruby will work on fine motor skills by forming the letters of her name in Theraputty 3/4 trials with one verbal cue by 5/10/2013. Activities: 1. Tissue Paper art- Therapist will instruct Ruby to create tissue paper art by writing a word of her choice and then placing tissue paper squares on the glue using training chopsticks. 2. Making paper chains- Therapist will fold a 8.5 X 11 size paper four times horizontally, then draw half of a shape. If Ruby feels comfortable have her draw shape. Therapist will then instruct Ruby to cut out shape with child safe scissors. Objective 2: Ruby will be able to independently complete a maze seated at a desk with auditory distractions while staying on task by 3/15/13. Activities: 1.Simon Says Game-Therapist will stand five feet away facing Ruby instructing her to do

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perform various gross motor and fine motor movements. One out of every five instruction should be an attention based activity. IE Simons says to sit and draw a picture of your favorite animal. 2. Skillstreaming Lesson 10 Ignoring Distractions The therapist will help Ruby identify why she needs to know how to ignore distractions. The therapist will then teach Ruby the steps to ignoring distractions. These steps are: Step 1: Count to 5. Step 2: Say to yourself "I won't look I'll keep working". Step 3: Continue to work. Step 4: Say to yourself "Good for me. I did it." The therapist will model using the skill at home, at school, and in the community while Ruby tries to distract the therapist. Ruby will then role play using the skill at home, at school, and in the community while the therapist tries to distract her. The therapist will then provide Ruby with feedback on her performance. Goal 2: Ruby will be able to independently select a matching outfit from her closet within five minutes by 6/22/2013. Objective 1: Ruby will complete an obstacle course including retrieving a ball from the ball pit, based on color; crawling through the barrel; the dropping the ball in the appropriate colored bucket to work on visual perceptual skills with four verbal cues by 6/20/2013. Activities: 1. Ruby will retrieve various small stuffed toys from ball pit. Using the plastic ball pit, the therapist will hide stuffed animals while Ruby hides her eyes. Ruby will start five feet away and be instructed to find the animal and bring it back. This will be a timed task. Therapist will have Ruby perform three repetitions of this task using large to small sized stuffed toys to increase

RUBY: A CASE STUDY OF A SIX-YEAR-OLD GIRL difficulty.

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2. Find the difference between pictures. Ruby will be seated at a desk with therapist seated next to her. Therapist refers to Mardi Gras Time activity book beginning on page 12, having Ruby identify five differences in the pictures. Continue with three of the same activities throughout the book. Objective 2: While seated at the table Ruby will replicate a 4-6 block pattern laid out by therapist using square blocks to work on form constancy independently 3 out of 5 trials by 5/1/2013. Activities: 1. Matching worksheet-Ruby will be seated at a desk with therapist seated next to her. Therapist will refer to page 11 in Mardi Gras Time workbook and have Ruby complete the activity. 2. Match shape blocks to shape cards- Ruby will be seated at a desk with therapist seated across from her. Therapist will place three wooden blocks on desk in front of Ruby and instruct her to match the shape of the card with the block. Therapist will perform this three times increasing block number 3, 5, 7. Therapist will record time it takes to complete task. Goal 3: Ruby will improve oral motor skills to safely chew and swallow a peanut butter and jelly sandwich with two verbal cues by 5/22/2013. Objective 1: Ruby will show improved oral motor strength by eating soft fruit safely and independently by 3/15/2013. Activities: 1. Webber Oral motor practice cards- Therapist will have Ruby complete five oral motor practice cards. 2. Chew art from cold cuts, cheese slices, and apple slices- Therapist will instruct Ruby to bite into various foods and create different patterns with her teeth marks.

RUBY: A CASE STUDY OF A SIX-YEAR-OLD GIRL Objective 2: Ruby will demonstrate safe chewing awareness by playing Foodland for 10 minutes with less than four verbal cues by 5/7/2013. Foodland is a version of Candyland where player eats a food corresponding to square color.

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1. Therapist will instruct Ruby to chew various foods using a bolus bag and identify how many chews that food requires to be swallowed safely. 2. Organize food cards into difficult, medium, and easy. Therapist will give Ruby 10 cards with various foods on them and instruct her to place the food into the appropriate pile based on how hard it is to chew. Occupational Therapy SOAP Note Occupational Therapy SOAP Note Date: 3/15/2013 Time: 1:00pm Subjective. Client complained of having difficulty focusing while at school, mother believes this could be related to ADHD. Clients mother reports of difficulty with chewing and feeding during meals, explaining that client does not chew her food enough. Client said she was tired because she didnt sleep last night and had little interest in participating in any activities. Objective . Client participated in a 60-minute OT session in outpatient clinic focusing on attention span, chewing/eating and visual perceptual skills. Attention Span- Client participated in a 20-minute fine motor and attention based activity requiring continuous verbal cuing to remain on task. Client periodically expressed frustration with inability to perform certain fine motor movements involving bilateral coordination and particular shape discrimination. Client demonstrated the ability to independently stay on the task for ~5 minute periods, then needing a 30 second break. Chewing/Eating- Client participated in a 20-minute oral-motor exercise activity focusing on

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chewing, swallowing and cheek/tongue ROM. Client specifically showed difficulty in oral-motor function involving tongue ROM. Client demonstrated limited rotary chewing involving hard table foods only swallowing ~25%. Client needed 2-3 verbal cues to sufficiently swallow soft table foods. Client demonstrated the awareness for the need to chew various textures longer than others. Visual Perceptual- Client participated in a visual discrimination activity needing 1-2 verbal cues to complete the task of finding a stuffed animal in the ball pit. When performing an attention based visual discrimination task in an activity book, client needed 2-3 verbal cues to find the differences in pictures. Assessment: Client demonstrated problems with attention span which will affect her success in school. Client also displayed problems with chewing foods sufficiently, resulting in safety concerns with independent feeding. Visual perceptual skills are an area of concern, particularly with visual discrimination, sequential memory, form constancy, and visual closure. These problems will affect clients performance at school and completing ADLs. Client has shown improvement in visual discrimination skills, requiring less verbal cueing to complete activities in book. Improvement has been shown in eating skills as client has recognized the need to chew harder texture foods more than soft textured foods. Client will benefit from continued OT services which challenge her selective attention abilities. OT services will help improve her visual closure skills, form constancy and sequential memory. These skills will benefit her overall academic performance in school. Plan: Ruby will continue to receive OT treatment 2x/wk for one hour, to improve attention, chewing/eating and visual perceptual skills. Future interventions should address selective attention, alertness, oral-motor strength, and visual perceptual skills.

RUBY: A CASE STUDY OF A SIX-YEAR-OLD GIRL Post-discharge? What specific recommendations would you make for this client/family?

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The post-discharge environments will be the school and home settings. The intervention activities administered in the outpatient clinic will all transfer to both environments. Recommendations to the school therapist and teacher are: continue working with Ruby on fine motor skills, pencil grasp, hand writing and safe and effective eating during lunch time. It is recommended that Ruby be seated in the front row in the classroom, closer to the blackboard. The recommendations for the family are: to utilize those activities focusing on increasing attentiveness and cognitive skills such as board games, puzzles, blocks and Theraputty. It is recommended that Ruby do a gross motor activity before meals. Parents should ensure that Ruby is seated upright in the chair during mealtime and foods with various textures should be gradually incorporated into her diet and meals should be related back to skills learned in Foodland game. Art and music therapy will help Ruby to stay on task with activities. During story time, picture books or audio books will be helpful. Parents can ask Ruby to retell the story after it has been read to her, to help her pay attention to it. (Hall, Kaduson, & Schaefer, 2002). It is recommended that Ruby see a developmental optometrist. The two in Las Vegas are Dr. Mary Grant and Dr. Mary Carrol. Playing activity books with Ruby will help with her visual perceptual skills, such as playing Wheres Waldo, connect the dots and matching games. These activities can be done while seated on a textured disc sit cushion, kneeling, laying prone on the floor or sitting indian style. (Case-Smith) Mighty Bright ruler magnifiers (Amazon.com) can be purchased to help with reading. Assessing the needs of childrens learning styles is important for overall classroom success and can be assessed by a learning styles questionairre created by Learn4Life Publishing Ltd which is also age appropriate for Ruby (U.K. Department of Education). Accounting for

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learning styles may help students pay attention because the material will be more appropriately stimulating to their sensory needs. This can be used by future educators since ruby is entering into formal education. This assessment determines if children have the prerequisite skills to cope with the first year of formal education, Key Stage 1. The research study shows the variety of skills children enter with and give out a questionnaire to help students meet their educational needs. Include one page of justification for the therapeutic intervention based on 3 peer reviewed journal articles. The primary reason we will be using Theraputty will be to increase strength in the muscles of Rubys hands. Studies by Sanghavi and Kelkar have shown there is a correlation between the ability to form letters with Theraputty and handwriting skills therefore we incorporated this into Rubys intervention. The population used in the study was significantly older and would have less potential for learning new tasks since neural plasticity decreases significantly after the age of seven (Lau). However, Sanghavi and Kelkar (2005) indicate improved scores of Visual Motor Integration, especially with clay modeling and other visual motor function activities under supervision of an OT. This will help her with visual discrimination, a skill that has shown to be delayed especially according to the sensory profile questionnaire. Ruby has many issues that interfere with her ability to ignore distractions. This inability to ignore distractions is severely impacting her occupational performance. Thus, it is important to explicitly teach Ruby how to ignore distractions in a concrete and easily understood manner. We decide to do this using the Skillstreaming program Skill 10 "Ignoring distractions"(McGinnis & Goldstein,1997). There is a substantial amount of anecdotal and evidence based support for the

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efficacy of Skillstreaming with many populations. Skillstreaming is commonly used to explicitly teach prosocial skills, such as ignoring distractions, to children with autism, Aspergers, ADHD, ED, etc. This program provides multi-sensory ways for a child to learn and practice skills in a step by step manner. Furthermore, children benefit from the steps of modeling and then roleplaying the skill before practicing using the skill during real occupations. Amendola and Oliver (2010) stated A large body of research shows that the three major areas [in Agression Replacment Training] of Skillstreaming, Anger Control Training, and Moral Reasoning address key dimensions in helping young people acquire prosocial behavior, thinking, and values. These approaches have withstood the test of time (p. 50). For example, The California Institute for Mental Health provided Aggression Replacement Training via highly skilled professionals to 3,482 children in a variety of settings and found that children showed increases in social skills of 11-40% as rated by the child, their parents, and their teachers (Amendola & Oliver, 2010, P. 49). Amendolo and Oliver (2010) also found that the Skillstreaming program improved the childs grade point averages. Ruby seems to have significant developmental delays in various visual components. To improve these skills, we have created an obstacle course that incorporates these elements. Parush and Hahn-Markowitz (1997) support this view in that the environment can be used to elicit an adaptive response. This study, looking at five to six year old children, used a variety of assessments looking at visual discrimination, postural, praxis, and body concept demonstrated knowledge. Subjects in the group using an obstacle course improved as a result of the intervention in the areas of balance, postural and constructional praxis, visual perception, visual motor integration, body image, following spatial directions, and finger dexterity.

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RUBY: A CASE STUDY OF A SIX-YEAR-OLD GIRL References Amazon.com. (2013). Mighty bright ruler magnifier. Retrieved from http://www.amazon.com/Mighty-Bright-36801-RulerMagnifier/dp/B000VZI3H6/ref=cm_cmu_pg_t Amendola, M., & Oliver, R. (2010). Aggression replacement training stands the test of time. Reclaiming Children and Youth, 19(2), 47-50. Retrieved from http://search.proquest.com/docview/852771079?accountid=28843 Case-Smith, J. & OBrien, J. (2010). Occupational therapy for children (6th ed.). St. Louis, Missouri: Mosby Elsevier. Dunn, W. (1999). Sensory profile caregiver questionnaire. San Antonio, TX: Psychological Corporation. Hall, T.M., Kaduson, H.G., & Schaefer, C.E. (2002). Fifteen effective play therapy techniques. Professional Psychology: Research and Practice, 33(6), 515. Learn for Life Publishing. (2007). What kind of learner is your child. Retreived from http://www.keystageplus.co.uk/learningstyles.pdf

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McGinnis, E., & Goldstein, A. P. (1997). Skill-streaming the elementary school child. Research Press. Parush, S., Hahn Markowitz, J. (1997). A Comparison of Two Settings for Group Treatment in Promoting Perceptual Motor Function of Learning Disabled Children. Physical and Occupational Therapy in Pediatrics, 17(1), 45-57. Retrieved from http://informahealthcare.com/doi/abs/10.1 080/J006v17n01_03.

RUBY: A CASE STUDY OF A SIX-YEAR-OLD GIRL Sanghavi, R., Kelkar, R. (2005). Visual Motor Integration and Learning Disabled Children. Indian Journal of Occupational Therapy, 37(2), 33-38. Retrieved from http://medind.nic.in/iba/t05/i2/ib at05i2p33.pdf

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Sparrow, S. S., Balla, D. A., & Cicchetti, D. V. (2005). Vineland-II, Vineland Adaptive Behavior Scales: Survey Forms Manual. NCS Pearson, Incorporated.