PNWU MOT | 4.1.

2024

OTH 545 Level I Fieldwork A:

Infants, Children, &

Adolescents
A Case Study

Presented By:
Annie Turtura
Occupational Profile
Client information Initials W.B.

Gender Male

Age 4 y.o.

Ethnicity Caucasian

Level of
Preschool
Education

Primary
Autism Spectrum Disorder
Diagnosis

Medical Mother carried to term with no reports of

History alcohol/drug abuse
Occupational Profile
Client information cont.

Lives with supportive mother and grandmother who are

Supports
involved in care and client’s success

Interests Fascinated with letters and numbers, puzzles, and bubbles

Reason for Sensory sensitivities, communication issues, restricted

referral interests, and motor skill delays
Occupational Profile
Levels of function and independence
Prior
W.B. had difficulties with feeding himself, dressing,
and using the toilet independently. He was unable to
communicate with speech and found it difficult to
regulate his emotions.
Current
W.B. avoids foods with certain textures but adequately
uses utensils. He is able to don shirt, shoes, and socks
with a little help, although the right and left orientation
may be incorrect. He is able to pull down simple
clothing (i.e. pants with elastic waist band)
independently. W.B. stills shows no interest in potty
training. He answers simple questions nonverbally,
says 2 to 3 words to label a person or object. W.B. is
prone to tantruming, particularly due to changes in
routine or not getting what he wants.
 Occupational Profile
Client factors

Values/Beliefs Body Functions Body Structures

Values reading Strengths Strengths
Prioritizes spending time Hyperlexic Normal muscle tone
with family Visual perception Barriers
Attends church/Sunday Attention to detail None identified
school weekly Barriers
Emotional dysregulation
Unaware of body position
and space
Difficulty crossing the
midline
 Occupational Profile
Performance skills

Motor skills Process skills Social skills

Strengths
Chases bubbles by walking,
reaching, and trying to
catch and pop them.
Barriers
Difficulty using both hands
at the same time
Difficulty cutting
Strengths Strengths
Follows directions with two or Expresses likes and dislikes
three steps
Barriers
Understands the concept of
Difficulty maintaining eye
letters and may know how to
contact
read
Does not play cooperatively with
Barriers other children
Uses behavioral responses or Avoids new experiences
gestures to communicate
Resists going to the potty
Occupational Profile
Performance Patterns

Habits Always turns on/off lights when entering/leaving a room

Follows an evening bedtime sequence to complete

Routines
toileting, bathing, dressing for bed, and reading stories.

Rituals Arranges favorite books in a particular way

Roles Son, grandson, and preschooler

 Occupational Profile
Context
Strength: Strongly values reading
Cultural
Barrier: Gets very frustrated/angry when it’s time to put reading materials away.

Strength: Only child living in an intergenerational home.

Personal
Barrier: Does not like to share/play with others.

Strength: Mom patiently uses a timer to indicate when it is time to switch

activities.
Temporal
Barrier: Transitions between activities occurs multiple times each day in
preschool without a timer.

Strength: Uses iPad to communicate

Virtual
Barrier: None identified
Occupational Profile
Environment

Physical Social
STRENGTHS BARRIER STRENGTHS BARRIER
Client has an iPad to Front and backyard Grandmother lives Single parent
help him communicate play areas are with and cares for family
Client has a sensory unfenced client
bed that provides a No family car Reliance among
controlled sleep members of a faith
environment community
Intervention
W.B. attends a Sunday school program. He has difficulty concluding his play to transition to a different activity.
When a transition is imposed on him, W.B. refuses by screaming and stamping his feet. W.B.’s difficulties with
transitions often disrupt the class and upset his peers.

Type Environmental modification

Visual Schedule
used to help with starting and
Description
finishing activities, and
transitioning between activities.

providing structure and routine

Supports the encouraging independence
client’s ability improving understanding
to engage in avoiding frustration and anxiety
occupations by providing opportunities to
interact with others.
Collaboration Process
W.B. receives OT and ABA services through a partnership between Children’s Village
and Catholic Charities.

While building rapport with W.B., the OT performed a

preference assessment to determine the hierarchy of W.B.’s
Client preferred toys, foods, and social interactions to be used as
motivators during therapy sessions.

The OT taught W.B.’s mother and grandmother strategies to

support his occupational goals and provided an individually
Caregivers designed home program intended to be incorporated into
W.B.’s routine.

The OT participates in regular service provider meetings with

ABA Therapist W.B.’s ABA therapist to discuss his progress and update his
treatment goals.
Health Promotion & Prevention
Level of prevention Tertiary

Promotes client’s health and wellbeing by collaborating with

his support team to identify goals related to his engagement in
valued occupations and by developing a plan to achieve
OTs role
targeted outcomes. Additionally, the OT modifies the client’s
outcomes to accommodate his changing needs, contexts, and
performance abilities.

By the end of 8 sessions the client will be able to discontinue

Expected outcome his play and consult a visual schedule to determine what he is
to do next.

Discharge
Developmental Preschool
Environment
 References
American Occupational Therapy Association. (2020). Occupational therapy practice framework:
Domain and process (4th ed.). American Journal of Occupational Therapy,
74(Supplement_2), 1-87. https://doi.org/10.5014/ajot.2020.74S2001

O'Brien, J. C. & Kuhaneck, H. (Eds.). (2020). Case-Smith's occupational therapy for children
and adolescents (8th ed.). Elsevier.