Arab American University – Jenin

Faculty of Allied Medical Science

Department of health sciences

# Clinical field work

Case study: Autism spectrum disorder

Produced by: Fares Ahmad Awesat

.ID: 201611548
Table content:

Demographic data and 3

social history
General description 4
Occupational History 5
Medical history 6
Diagnosis 7
ICF 8
Frame of reference, 9-10
approach, model
Clinical reasoning
Assessments 11-14
Summary of main problem 15
Long and short goals and 16-17
method and activities
Treatment session 18
Functional progress 19
Recommendation and 20
references
 Demographic Data

Name: GH.KH.KH
Gender: female
Dominant Hand: right
Date of birth:11.8.2011
Date of admission:14.10.2011
Address: Bayt- fajjar Bethlehm

Diagnosis: autism spectrum disorder

General description of client (physically, behaviorally, and
:socially)

Physically: GH. Came to the occupational therapy department in hope

flower school with her parents, GH. came with beautiful appearances, has
normal physical appearance (weight and height), wearing clean clothes,
walking independently, GH is able to walk and run and climb stairs up
and down independently, and move normally without any help or any
special device.

Her dominant hand is the right hand

Behaviorally: GH love to come to the sessions; but she doesn't cooperate

all of the time.GH has problem in paying attention and she get distracted
quickly from any voice or movement around her, also GH has poor
orientation to the time place and person. She prefers to play alone in quiet
environment because she get anxious and aggressive in loud environment.
She has stereotyped movement such: standing and start to jump in the
same place. In addition, GH show low tolerance during activities and she
is hyperactive

Socially: GH is considered unsocial, she has poor social interaction with

others, and poor communication skills, she has problems in verbal and
non-verbal communication skills, she is unable to initiate and maintain
conversation and unable to build relationships with others, also she has
poor eye contact, she doesn't prefer to collaborate and engage in activities
.with a group all the time and need motivation
 Occupational history profile and cultural background

Cultural background: GH is 10 years old, has been diagnosed with

sever autism, she live with her family;her parents and her sister and she is
the oldest in her family, they live in there own house and the economic
status is very good, her father work in and her mother is a house
keeper

BADL: GH is almost full dependent

Sleep Rest: sleep 7 and more hours but she take long time to sleep

Environment and the context

GH has supportive family and they live in Bethlehem

.:Home condition

Education: M student at kindergarten.

Social participation: prefer to play alone not with others.

Physical environment :Her family has a good economic status, the

house consist of.

Social environment : unsocial, she has poor social interaction with

others, and poor communication skills, she has problems in verbal and
non-verbal communication skills.
 Medical history:

Past history:

Surgeries: no previous surgeries.

Present history:

She didn’t take any medication she received 5 sessions session per week
in occupational therapy autisim department in the Hope Flower School

And she take 3 sessions in speech therapy

Diagnosis: medical

autism spectrum disorder (ASD) is a developmental disorder that affect

communication and behavior. Although autism can be diagnosed at any
age, it is said to be a "Developmental disorder " because symptoms
generally appear in the first three years of life.

According to the diagnostic and statistical manual of mental disorder

(DSM-5), people with ASD have:

 Difficulty with communication and interaction with other people.

 Restricted interests and repetitive behavior

Symptoms that impedes the person's ability to function properly in

school, work, and other area of life.

Autism is known as a “spectrum” disorder because there is wide variation

in the type and severity of symptoms people experience. ASD occurs in
all ethnic, racial, and economic groups. Although ASD can be a lifelong
disorder, treatments and services can improve a person’s symptoms and
ability to function.

Clinical diagnosis:

GH is 10 years old female and has been diagnosed with sever autism in
28.5.2014 (3 years old) by neurologist doctor and after that her parents
admission her in the autism pediatric department in Hope Flower school

GH has a lot of stereotype movement such as stimming”. It includes

repetitive behavior such as rapidly flapping her hands, rocking also
screaming, hit things to make loud noise so she get auditory sensory
stimulation and cover her ears when there is noise and sometimes she
harm herself by hitting her head to the door or the ground.

Also she has problem in speech and communication (verbal and non-
verbal) and prefer to stay alone.
 ICF-International classification function
 Health condition: she considered healthy, and did not take any
medication. she takes occupational therapy sessions at hope flower
school. Her diagnosis is sever autism spectrum disorder (ASD).
 Body function and structure:

Functions: Problem: hyperactive, poor fine motor, memory, language,

problems in sensation (she is seeker), social participation, social
communication.

Structures : no physical deformities noticed.

 Activity:

Abilities : GH able to walk, transfer, she has head and trunk control.
Respond to simple instruction such as: give me, take…

Limitations: there are a lot of limitations such as limitations in

communication skills(comprehension, expression),and social interactions
skills, limitations in concentration and attention, ADL. Bilateral hand use,
Eye hand coordinatin

 Participation:

Abilities: she plays activity that include running and spinning but not
playing properly, and rarely played with other children.

Limitations: poor social interaction with others.

poor communication skills and poor initiation on all activities.

 Environmental factor:

Physical environment: Live with her family in their own house that
consist of :

Social environment: GH has supportive and caring family

Personal factors:

GH is 10 years old female

Frame of references:
frame of reference may be defined as: “A system that applies theory and puts
principles into practice, providing practitioners with specifics on how to treat specific
”clients” (Hussey, et al., 2007 p, 288) Its function: “Guides a specific area of practice

:Biomechanical frame of reference

The biomechanical frame of references is a remediation or restoration

approach, this approach is based on joint range of motion, muscle
strength, and endurance with the intact central nervous system.

*is a bottom-up frame of reference, useful for understanding occupational

performance capacity in more detail. I applied this by improving her fine
motor skills, so she could eat independently, hold the drawing brush. and
also perform passive exercises

Sensory integration frame of reference:

The Sensory Integration (SI) frame of reference focuses on how the

interaction between the sensory systems including auditory, vestibular,
proprioceptive, tactile, and visual systems, provides integrated
information that contributes to a child’s learning and adaptive behaviors.
The key consideration is that children have the abilities to make adaptive
responses to constantly changing sensory environments. The sensory
integrative abilities include sensory modulation, sensory discrimination,
postural-ocular control, praxis, bilateral integration, and sequencing. In SI
frame of reference, the outcomes of sensory integrative process consist
of:

1. The ability to modulate, discriminate, and integrate sensory

information from the body and from the environment,

2. Self-regulation to regulate and maintain his/her arousal level to

focus on task, I use this approach to enhance her attention and
concentration problems and gave her sensory stimulation as much
as possible such as putting the brush on her body specially her
hands and rubbing it, also working in the sensory room to reduce
stress and to gain sensory stimulation
Approaches:

 Family centered approach: provide adequate information

and support for the family to make decisions and it is a way
of working with their child to enhance their capacity to care
and protect their child, also about what the family need to do
to improve their son behavior, or what the family needs to
change, to achieve optimal outcome.

I used this approach to fill assessment and put the goals and to
gain information about GH`s interests, weakness/strong points,
what type of play she like and to involves GH with her family
in home program and strategies during the corona pandemic
and the lock down that affect the public services.

 Educational approach:

We use educational approach in teaching the patient exercise to

do in home, and educating his parents about the importance of
treatment to achieve the main goals for the child and the
importance of following instruction at home.
I used this approach at the end of every session; we educate
GH`s mom about her case, improvement, and giving her a plan
for home.

 Cognitive approach:
It focuses on to enter the external information from the
environment to body human; and processing this information
in the brain and finally providing suitable respond to the
condition.

And by that the activities that I used them with GH during treatment
sessions promote and improve the cognitive skills through the activities
such (attention; concentration; memory and problem solving by using
Puzzle, putting the beads in thread).
MODEL:

The Person-Environment-Occupation (PEO) model is a model that

emphasizes occupational performance shaped by the interaction between
person, environment, and occupation. The person domain includes role,
self-concept, cultural background, personality, health, cognition, physical
performance, and sensory capabilities. The environmental domain
includes physical, cultural, institutional, social, and socio-economic
environment. The occupation refers to the groups of tasks that a person
engages in and meets his/her self-maintenance, expression and fulfillment

I choose this model because it is the most appropriate model that

encompasses all the following domains:

-Applied to individual and groups.

-Focus on the situation of the client.

-Allows practitioners to asses intrinsic and extrinsic factors. .

-Matches between goals of the client and goals of the occupational

therapy.

-Outcomes must be related to well – being and quality of life.

Clinical reasoning:

Clinical reasoning is the process by which a therapist interacts with a

patient, collecting information, generating and testing hypotheses, and
determining optimal diagnosis and treatment based on the information
obtained. It has been defined as “an inferential process used by
practitioners to collect and evaluate data and to make judgments about the
diagnosis”.

1- Ethical clinical reasoning:

To maintain the confidentiality of the patient and not to disclose
any
2- Interactive clinical reasoning:
Involves collaborating with the client, Therapist must gain client’s
trust and enter the world of the client, gain better understanding of
client and how to help the client in the best way, also build a
positive therapeutic relationship.

3- Procedural clinical reasoning:

Involves addressing functional limitations, it’s a strategy used by
the OT practitioner to focus on the client’s disease and determine
what will be the most appropriate modalities to use to improve the
clients functional performance. I used it by choosing the most
appropriate Assessment, activities to reach the goals.
:Non- standardized assessment

 Observation:
I observe GH while doing the activities, eating, dressing, interact with others
(friends, teachers, and other therapist), her facial expression, speech; Riding the bus
also I observe her limitation in motor skill (fine motor skill) and during the sensory
.activities

And due to that I succeed to locate her limitation

 Interview:
It was done on the phone because GH`s mother couldn’t come to the
school, it took about 40 minutes at first a identify myself to her and
start to take information about GH such as: demographic data, social
and cultural history also her medical case and she was cooperative
and that helped me to get the holistic picture about GH`s condition.

 Medical report: I used her medical file report at school; I took the
basic information that i need about GH and the medical speech and
occupational therapy reports.

STANDRIZED ASSESMENNTS:
:Main problems

 Limited bilateral use

 Lack in social interaction
 Limited eye hand coordination
 Lack of attention
 Lack of problem solving.
 Problem in speech(verbal and non-verbal)
 Hyperactivity
 Dependent in most of ADL
 Lack of motor planning.
 Low tolerance during activities
 Auditory over sensitivity
  Long-term goal (1):

GH will be able to play (Lego game) with 2 therapist at least to

improve social interaction and participation in school from maximal
assistance to minimal within 4 weeks.

Short-term goal:

1- GH will be able to share toys with others and playing in group activates
(three person) with 25%verbal cues in 4 weeks.
2- GH will be able to improve eye contact with person who talks to her
with 25%verbal cues within 4 weeks.
3- GH will improve eye follow with 25%varbal cues within 4 weeks.

 Long-term goal (2):

GH. Will be able to eat with bilateral hand use( juice and sandwich)
with minimal supervision within 4 weeks.

Short-term goal:
1. GH will be able to improve eye hand coordination from maximal
assistance to minimal with 25%verbal cues within 4 weeks.
2. GH will be able to pick up food items (sandwich and juice)from flat
surface from maximal assistance to minimal with 25%verbal cues
within 4 weeks.
3. GH will be able to grasp, relies food objects(sandwich and juice)with
25% verbal cues within 4 weeks.
4. GH will be able to transfer and manipulate food objects(sandwich and
juice) from maximal assistance to minimal within 4 weeks.

 Long term goal (3):

GH will increase ability to tolerate tactile stimulation 90% of the

time during school time within 4 weeks.

Short goals:
1. GH will be able to stand in line (with three persons: one therapist and
two classmates) 90% of the time from maximal assistance to minimal
within 4 weeks.
2. GH will be able to hold hands (two classmates) while group activity in
school 90%of the time within 4 weeks.
Activity Aim
Hold two objects in two hands Enhance bilateral use
Catch a ball Enhance bilateral use, concentration,
social interaction, eye hand
coordination
Cutting shapes Enhance eye hand coordination,
concentration, bilateral hand use
Beads inside threads Enhance concentration, eye hand
coordination
Use tweezers to pick up small objects Enhance concentration, eye hand
coordination, fine motor
Sand slim Enhance sensory integration

Paint with the hands(sometimes in Enhance sensory integration and social

group) interaction
Sensory board Enhance and gain sensory stimulation

3. GH will be able to shake hands with others while group activity with
25% verbal cues within 4 weeks.

:BILATERAL HAND USE

 Hand over hand

 Verbal cues
 Modeling

:SOCILA INTERACTON

 Verbal cues(shake hand, wave your hands)

 Group activities
TOLERATE TACTAILE STIMULATION:
 Verbal cues
 Hand over hand
 Imitation