CASE

STUDY By: Andrea Padilla

PRESENTA
TION
 OCCUPATIONAL PROFILE

• Client: JJ is a 3-year-old happy and affectionate male

• Ethnicity: Hispanic
• Medical history: SOx2 Gene mutation
• Reason for referral: delayed gross motor skill acquisition
• level of function/independence: currently he is 100% dependent on his parents for all ADLs . He
receives all his nutrition from a G-tube and requires assistance to take Medication. His prior level of
function is unknown.
• Interest: Kicking toys, soft blankets (especially on face), old mc Donald song
• More: Non-verbal
 • values/beliefs/spirituality: Loves kicking toys
• body functions:
Barriers: Missing corpus callosum, Severe to
moderate hearing, can not sit upright
Strengths: Self calming
CLIENT FACTORS
• body structures:
Barriers: Born with no eyes, extreme muscle
tightness, knowing where body is at in space
Strengths: explores environment with feet
(protective mechanism)
 Barriers
• JJ was born with no eyes which affects his ability to
explore his environment. Because of this, knowing where
his body is at in space is challenging.
• JJ has delayed motor skill acquisition making it difficult
for him to sit upright. This also limits his level
independence, making him 100% dependent on family for
CLIENT all ADL tasks
FACTORS • Communication challenges impact his ability to
communicate his needs. JJ does not like straps which
make bathing difficult for him
Strengths
JJ has a supportive home environment with a supportive
loving family.
 PERFORMANCE SKILLS

• Motor Skills
Barriers: delayed motor skills, has not started holding head up, ridged movements
Supports: fine motor skills. Able to hold items in his hands, uses feet and hands to explore
• Process skills
Barriers: cognitive difficulties, does not respond to yes or no questions or follow simple instructions
Strengths: easily calms self
• Social interaction skills
Barriers: Non-verbal
Strengths: auditory discrimination, vocal recognition, hearing device
 Supports
• Habits: daily routines such as eating, sleeping, and self-care.
• Routines: selfcare, playtime, therapy sessions, and mealtimes.
• Rituals: family traditions, family gatherings
• Roles: son and nephew

PERFORMANCE Barriers
1. Extreme Muscle Tightness: muscle tightness may limit his
PATTERNS ability to move and explore his environment independently.
2. Resistance to Touch: resistance to touch can make certain
activities, such as bathing or teeth brushing, challenging.
3. Dependence on G-tube: JJ's dependence on a G-tube for
nutrition may limit his ability to participate in mealtime
routines with his family and develop feeding skills
 CONTEXT AND ENVIRONMENT
• Cultural:
Strengths : multigenerational living
Barriers: Non identified
• Personal
Strengths: Loving and happy
Barriers: Limited resources in
community
• temporal
Strengths: Adjustment to routines
Barriers: delayed motor skills
Physical:
Strengths: lives a supportive
home
Barriers: Rural community
Social:
Strength: mom, dad, uncle and
aunt provide a loving and
supportive environment for
him.
Barriers: Limited social
engagement
 INTERVENTION

Therapeutic Interventions:
• Rolling Side to Side: develop a sense of spatial orientation and encourages use of different
muscle groups. It also encourages bilateral coordination
1. Touching Head, Knees, Nose, Mouth, Toes: helps understand where his body parts are in
space, improving his body awareness and coordination.
2. Sitting Upright: develop core strength and stability, which are essential for maintaining
proper posture and participating in ADLs
 • Collaborate with ST to work on oral motor feeding,
while OT works on sensory aspects of feeding
• Collaborate with Caregiver to talk about home
COLLABERATION modifications to improve bathing routines and other
ADLs
 how OT services will promote health and
prevent further complications
OT can recommend environmental modifications
to JJ's home to make it more accessible and
supportive of his needs, reducing the risk of
accidents or injuries. motor skills such as rolling,
HEALTH sitting upright will allow him to explore his
PROMOTION AND environment enhancing his independence in daily
activities
PREVENTION
• discharge environment: Support groups, Home
environment
• expected or observed outcomes of OT
services: improved posture, feeding, sensory
processing, body awareness
• level of prevention : Tertiary
 REFERENCES

• American Occupational Therapy Association. (2020). Occupational therapy

practice framework: Domain and process (4th ed.). American Journal of
Occupational Therapy, 74(Suppl. 2), 7412410010.
https://doi.org/10.5014/ajot.2020.74S2001
• Kisling, L. A., & Das, J. M. (2023, August 1). Prevention strategies. In
StatPearls. Treasure Island, FL: StatPearls Publishing. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK537222/