Reflective Diary Entry

Lauren Beck
Oct. 1, 2019

Factual Strand

June 21, 2019

9:00 AM

Carter* is a 22-month-old who uses a nasogastric (NG) tube for his primary nutrition

source since birth. He is being seen today at an outpatient pediatric clinic in order to increase his

solid food repertoire. The supervising therapist, Ricki*, will treat Carter during this first therapy

session. I am instructed to take an observational role since the client is experiencing more

complicated feeding difficulties than most pediatric occupational therapists are accustom to

treating. Ricki prepares the treatment room by placing a large mat on the floor covered with age

appropriate toys. Snacks and feeding tools such as a Nuk brush, vibrating crocodile and z-vibe

are set on a plate on the table in the room. Food items include goldfish, graham crackers, fruit

purée, icing, yogurt, and peanut butter.

Carter enters the clinic being carried by his father; he is greeted by Ricki and myself and

demonstrates no response to his name. The therapist encourages the parents to let him explore

the clinic for a few minutes before we get started and communicates to the family that this

session will be about building rapport and observing his reactions to various food items. Carter

runs with outstretched arms to the ball pit, requires assistance climbing the three stairs to the ball

pit. He walks with an unsteady gate and attends to most activities or toys for 2-3 seconds before

moving on to the next activity. He spins various gears on the “gear alligator” for 10-30 seconds

each and repeated throws balls from the ball pit. During the session the following observations
were made: decreased eye contact, aversion to various textures, decreased attention to activities

in comparison to his peers, and is nonverbal at this time.

Physical assistance is provided to direct the client into the treatment room. Carter motions

to his mother to pick him up. The client explores the toys on the floor after about 10 minutes of

sitting in his mother’s lap. The therapist attempts to play with the client, he walks to the opposite

side of the mat where I am seated. Although Carter does not maintain eye contact or use verbal

communication during the session, he reaches for and grasps toys that are offered to him and

discards them after several seconds. Ricki hands me various items with yogurt, peanut butter,

and fruit purée on them and instructs me to take over since he is closer to me. For the remaining

35 min I attempt to interact with Carter. Each time I present a food item, Carter turns his head

and covers his mouth with his hand. When toys are presented he reaches, grasps, then releases

grasp allowing the object to fall to the floor. He maintains eye contact with the object for several

seconds before dropping the item, gaze does not follow the item to the floor. Food is placed on

balls, which is a preferred toy. Carter cried when he accidently touched soft food while

attempted to throw the ball.

July 5, 2019

9:00am

Today I am the treating student clinician for Carter’s therapy session. Before he arrives

the gym is set up with an age-appropriate obstacle course and the cuddle swing is hung. Various

tactile mediums are gathered (water beads, peanut butter play dough), grocery cart activity is set

up and the kitchen table is prepared for a food exploration activity.

While Carter completes the obstacle course with my assistance, I educate the parents on

what goals we are working on today. I correlate each activity to skills that are being addressed.
Parents are encouraged to participate in the obstacle course, tactile exploration, and feeding

activities. Carter attends to tactile exploration and shopping cart activity for several minutes.

During the feeding activity his highchair is turned towards me; his eye contact increases to

several seconds. Parents are educated on things to try to improve Carter’s participation in

mealtimes at home.

Retrospective Strand

June 21, 2019

I was unprepared to treat the client, unprepared to give parent education, and unclear

about the expected and projected process of therapy. I felt put on the spot with no time for

research or planning. Overall, I was uncomfortable. It felt as though I had three adults watching

me repeatedly fail while trying to play with a toddler. I could not connect what we were doing as

therapeutic and therefore assumed the parents were having a hard time thinking this was worth

their time. I discovered that therapists sometimes do not have a clear treatment plan, especially

when meeting a client for the first time. Although I was uncomfortable with not having a detailed

plan, the supervising therapist was calm due to past experiences with facing the unknown. I

learned how important it is to read the initial evaluation before I see a client for the first time. I

filled the silence with asking questions that were most likely covered in the initial evaluation.

Being a parent myself influenced how I viewed this session; I would want to know more about

what to expect, how long I should expect to bring my child to therapy, and what I could do at

home to support the process.

July 5, 2019
 Although I did not have all the answers, I was prepared and confident that my treatment

plan was appropriate for the targeted goals, therefore I experienced a sense of calm. I enjoyed

having the parents involved in the therapy process. I knew what performance skills I was

addressing and how to communicate that to the parents. I relearned the importance of creating,

preparing, and adjusting the environment.

Substratum Strand

June 21, 2019

I had no previous experience with feeding therapy for a child who does not tolerate

anything in or around his mouth. I felt like what I was being told to do was in contradiction with

past lectures on feeding and sensory processing. I believed that therapists should have more

structured therapy plans. I value open communication and a cooperative relationship with clients

and their families. In the past I had relied on my supervising therapist to have all the answers for

me and the clients. In retrospect I had no idea what the parents had expected would come out of

their initial therapy session. I had some idea of their goals for feeding but did not know how

quickly they expected to achieve that. Most of my concerns could have been absolved with a few

minutes of reading the initial evaluation, increased communication between me and the

supervising therapist, and increased communication between the therapy team and the family.

July 5, 2019

I had consulted with an experienced occupational therapist and a speech language

pathologist who specialized in feeding. I communicated with the client’s behavior specialist to

confirm we were building on each other’s interventions, not overlapping services. I relied on past

experiences with clients and built upon on Carters strengths and preferred activities. I value
evidence-based practice and believe that communication with caregivers is instrumental in the

therapeutic process. I learned that my initial perspective of expecting the supervising therapist to

have all the answers was unreasonable, she was just as motivated as I was to find potent

interventions as I was. Time and communication increased my understanding of these

perspectives.

Connective Strand

In the future I can identify how I am feeling during an unexpected incident. Instead of

becoming embarrassed or frustrated I can communicate to the client or caregivers what I intend

to work on and let them know I will do further research for unique cases that I have little

experience in. In the moment, I can take a moment to draw on experiences from the past where I

focused on the basics. I will identify and use the client’s strengths as a vehicle for change; then

adapt the activity or environment to create a “just right challenge” in order for the individual to

be successful. This experience has increased my desire to continue to learn through staying

current with research practices and attending specialized certification classes. For example, if I

continue to treat feeding issues I would attend an SOS training or something similar in order to

give the best care to my clients.

*Pseudonyms are used in the recounting of an occupational therapy session to protect

confidentiality of my client, their family, and the supervising therapist.