Client’s Overview of Occupational Profile
Client Name: Ivan Age: Eight years-old (8) Practice Setting: Elementary School
Main reason that has prompted need for OT services: Washington State IEP (year 2023) showed that Ivan had difficulty with fine motor skills, writing challenges, and difficulty with his scissor grasp. Past IEP also showed that Ivan demonstrates challenges with social skills, interacting with others, and auditory sensitivity. Ivan’s father requested for an evaluation now that they have moved to Illinois, and he is in a new school system. This prompted Occupational Therapy to be part of the special education evaluation for a new IEP.
Overview of client’s Occupational Profile:
Ivan is an 8-year-old, a second-grade student who attends an Elementary School in Illinois. He recently moved from Washington State where he lived with his mom and had an individualized education plan. He is now living with his father, his legal guardian. Ivan’s father requested a new evaluation for special education. Ivan has a diagnosis of autism, severity level of 2, with challenges in verbal and nonverbal communication, social interactions, and resistance to changes in environments that impact his daily routine or cause unusual sensory experiences (e.g. loud noises, too much movement). His father expressed to the schoolteacher that Ivan experienced negative emotional and verbal interactions during his previous home environment, but that Ivan is no longer exposed to those people. Father mentions that Ivan interacts well with others outside of school.
Ivan’s past IEP evaluation showed that Ivan is not yet able to hop on one foot, gallop, do jumping jacks, or skip. Ivan stops motor movements if they are too challenging. His teacher expresses that he shuts down when he becomes frustrated and that if there is a change to the day schedule or something is unclear, Ivan becomes withdrawn, no eye contact, refuses to talk, and is unable to complete the task at hand. Ivan usually needs prompting to respond and has auditory sensitivity (e.g. sound when flushing the toilet). Both his last IEP and his current teacher report that Ivan has difficulty with line adherence, spacing, and letter size when writing and that his writing skills decrease without a model. He takes a long time to warm up to someone new, as it is a change in his routine.
Currently, Ivan has the following class accommodations and supports: A daily visual schedule is posted on the board so that he knows what to expect and so he knows when a break is coming. He is allowed frequent breaks to allow for more engagement in class participation and performance. His environments should have reduced or minimized distractions and should offer a consistent structure and with advance notice of changes. Ivan should be made aware of any schedule changes ahead of time to help with self-regulation. Ivan should be provided with specific and immediate feedback and lessons should be broken down into small units (multi-step directions should be broken down and directions should be read to him). He is inside the general education classroom 40-79% of the day and is currently working on copying sentences, work lists, and asking for help to build self-advocacy in the self-contained classroom.
Top-Down Occupation Based Theory or Model
Person- Environment-Occupation-Performance model (PEOP) ( Christiansen et al., 2015)
The PEOP model will help guide the occupational therapy process of Ivan by learning how well he does in school related tasks, activities, and roles as a student (performance), his level of engagement in those activities, tasks, and roles (participation), and his satisfaction, quality of life, and health both in school and at home.
This model takes into consideration person factors (Cognition, psychological, physiological, sensory, motor, and spirituality) and environmental factors (social support, assistive technology, natural environment, culture, social support, social determinants of health and social capital, and public policy). All these factors are very important to gather in order build rapport with the client, learn about barriers and strengths impacting participation and performance in the child’s learning and education, and guide occupational therapy through appropriate interventions.
Occupational Therapy Evaluation Strategy:
Methods that can be used to develop the client’s occupational profile include speaking with the parent, teachers, and other professionals that know the student. Another evaluation strategy involves using the AOTA’s Occupational Profile Template (AOTA, 2020) which can give history and current information about their daily living at home and at school, experiences, contexts, and the student’s interest. This profile is focused on what the student shares and can be difficult to start off with this profile if the student has not built that trust and comfort with the therapist. One way that the therapist can engage in an occupational profile can be through play of child’s favorite activities, such as building Legos.
Methods that can be used to complete an analysis of occupational performance involve observation and analysis of activities the child engages in during his time at school. These observations can be done in the classroom setting where the therapist can see the child in their class environment. They can also take place in other school environments such as PE class, lunchroom, library, and music class. Observations can also happen one-on-one, where the child engages in chosen activities provided by the therapist. These observations can give valuable information on barriers and facilitators a child has in school. These observations take place in a school setting; therefore, activities might include play, attention skills, fine motor, posture, writing skills, social participation, and visual motor. Therapists can also look at observations and notes made by physical therapy, social workers, nursing, or other school professionals.
Additional assessment tools that may be used in the analysis of occupational performance and the information gathered could include (but not limited to):
- Bruininks-Oseretsky Test of Motor Proficiency Third edition (BOT-3): screening of motor development and performance for school age to early adulthood. OT can focus on Fine motor precision, fine motor integration, manual dexterity, upper limb coordination, and bilateral coordination subtests.
- The Print Tool: this assessment can help assess Ivan’s letter formation, sizing, spacing, and legibility of his writing. This way, OT can get a clear profile of his strengths and areas where he can improve with the proper supports and interventions.
- Beery-Buktenica Developmental Test of Visual-Motor Integration sixth edition (BEERY VMI): this assessment can help identify if the child is encountering difficulties in visual motor integration. This is important to note as Ivan has difficulty with writing skills without a model.
- Social Skills Improvement System (SSIS) Rating Scales: assesses social skills and challenging behaviors of students. The overview profile gives a nice picture of general skills Ivan has based on teacher observation. Ivan’s father feels that Ivan interacts well with others outside of school. This assessment can help get more standardized information as well as observations.
- Teacher Report Form (TRF): this questionnaire is designed to obtain teacher reports on a student’s academic performance, adaptive functioning, and behavioral-emotional challenges. This will help OT gage how to plan for interventions, what accommodations, or sensory techniques to have planned out for sessions times, etc.
Based on the information provided by teachers in his overview, I do not feel that the Child Occupational Self-Assessment (COSA) would be a good option for my client, as he will reduce his engagement and shutdown if he is not understanding.
Another assessment that the occupational therapist can view based on the clients IEP primary Eligibility would be:
- Adaptive Behavior Assessment System Third Edition (ABAS-3): this assessment will allow for three rating forms that meet with Ivan’s age (Parent, teacher, and adult form). These forms will allow for a more complete assessment of Ivan’s everyday activities and how he functions, cares for himself, interacts with others, and meets his environmental demands. It will help give important information needed to make the most appropriate interventions and clinical decision making.
Hypothesis about the client’s occupational performance strengths and needs.
Ivan is very sweet, eager to learn, enjoys math, playing with peers, and engaging in daily center rotations. He does a nice job at identifying hi feeling. He is working on his communication skills with other students and adults. It takes him a long time to warm up to someone new as it changes his routine. Ivan has challenges if there is a change to the day schedule or is something is unclear where he become withdrawn, does not make eye contact, refuses to talk, and is unable to complete the task at hand. Ivan is also working on auditory sensitivities in the classroom, hallways, bathrooms, and other school areas. He is also having difficulty line adherence, spacing, and letter size when writing and that his writing skills decrease without a model. These challenges are impacting his roles as a student such as peer group participation, self-advocacy with new individuals, and formal education participations. Ivan needs to be prompted to receive a response. The teacher also notices that he has difficulty with social skills in engaging in playtime with other children.
Ivan really loves to learn, and it will be important for OT to follow his current school accommodations and see if there are other accommodations that would be beneficial for all school professionals and adults outside of school to do as well. It will take Ivan some time to get used to OT and OTA and this is very important to note because it can impact results in assessments done during evaluation. Giving teachers and Ivan an advanced notice that OT will be coming, will be an important step to build rapport with Ivan.
Overall Outcomes that would be targeted through OT Services
Ivan will communicate his likes and dislikes during group activities with his peers using communication cards or verbal statements with no more than 2 prompts as measured by teacher feedback. This will give the opportunity for Ivan to start practicing social and communication skills and increase his self-advocacy.
Ivan will demonstrate improvement in fine motor and visual motor skills to support his participation and success in his learning and education setting.
Ivan will complete visual motor integration activities such as hidden pictures, word finds, puzzles and copying complex shapes to help him continue developing awareness of his space (surrounding environment), knowing what his eyes see with his body movements, and his hand-eye coordination.
Occupational therapy contribution to the evaluation process
Occupational therapy will be involved in the group meeting with parents and other school professionals to determine which assessments or screeners to complete and most applicable for OT to do. OT will share assessment findings and observations to the rest of the team to build the proper supports, goals, and interventions for Ivan. Occupational therapy will express Ivan’s occupational needs that will increase his participation, performance, and overall well-being in the school setting to the rest of team. Working together with the parent’s and the rest of the tea, OT will determine the most appropriate goals and priorities for Ivan. The Occupational Therapist will also work with the COTA for assessments and developing the proper intervention plan based on the evaluation results. It will be beneficial to have the COTA in these meetings if possible as they will be working on the intervention plans with Ivan, and the COTA needs to build that trust with Ivan.
Contributions of a Certified Occupational Therapy Assistant (COTA) for evaluation
The COTA can provide administration of assessments chosen if they have demonstrated competency of those assessments. They will be able to provide written reports of those assessments, observations made, and analysis of Ivan’s performance to the occupational therapist.
Considerations for the evaluation process
The first step of the evaluation process involves having a group meeting to discuss what information we already have about Ivan, listen to parent concerns, answer any questions his father might have or information he would like to continue sharing to build Ivan’s profile and determine what additional information is needed. As a team, we will determine what evaluation needs should be completed and who will complete those evaluations. Next, those evaluations will be completed within the timeframe given and the team will then have an eligibility determination meeting to see if Ivan will continue to qualify for special education services (as he does have a past IEP from Washington State). If Ivan does qualify, the team will create his Individualized Education Program and determine what services he will receive along with continued school accommodations.
Occupational therapy intervention planning
Additional Theories, Models, or Frames of Reference to guide the OT Intervention Process
Environmental Press Model (Cole & Tufano, 2020)
- Focused on the individual’s skills and abilities and the demand of the environment they are in.
- Maladaptive behavior happens when the demand of the environment exceeds the individuals’ skills and abilities.
- Marginally adaptive behavior happens when the demand of the environment is challenging and stimulating and stressful to the individual.
- This model will help us match Ivans skills and abilities to the proper environment for him to be successful in the school setting.
Social Learning Theory (Cole & Tufano, 2020)
- Behavior that is learned through observations and imitating others who are doing the desired skill.
- Interventions include modeling, role-playing, and demonstration.
Frame of Reference for Development of Handwriting Skills
- This FoR focuses on proximal posture, use of writing tools, pencil grasp, and handwriting along with visual perceptual skills.
- This FoR can help identify areas to help with his line adherence, letter size, and spacing between words and letters. This might include visual supports for him.
IEP Team Goals appropriate to the school setting
- With no more than 2 prompts from an adult, Ivan will communicate his likes and dislikes during group activities with peers using communication cards or verbal statements 3/5 opportunities recorded by teacher log by the end of the school year. (Connected to SEL standard 2C.1a. Identify ways to work and play well with others).
- Ivan will independently communicate when he is feeling frustrated and needs help with adults (e.g. ask for help, express how he feels) on 4/5 observations recorded and verbally stated by staff by the end of the school year. (Connected to SEL standard 1A.2a. Describe a range of emotions and the situations that cause them).
- With role playing and modeling, Ivan will show friendly interactions (e.g. eye contact, playing a game, smiling) with peers on 3/5 observations as recorded by and verbally stated by staff by the end of the school year. (Connected to SEL standard 2C.2a. Describe approached for making and keeping friends)
Intervention strategies that could be used to address goals listed above.
- Social Stories (O’brien & Kuhaneck, 2020, pp. 352-353): this will help students develop social skills where children understand different concepts, routines, overcome fears etc. It prepares children to know how they might feel and what they should do in those situations. Sentences are usually descriptive, directive, perspective, and affirmative sentences. Stories should remain brief. We can read them out loud for Ivan and have pictures of himself or someone he likes to see (like a hero or favorite character).
- Video Modeling (O’brien & Kuhaneck, 2020, pp. 352): this is a video that the student can model and can help with addressing social communication skills and functional skills. The student will be able to repeat these videos repeatedly to build skills through practice.
- Stress Thermometer (O’brien & Kuhaneck, 2020, pp. 355): this intervention strategy can allow students to recognize and describe different levels of their emotions and behaviors that can help them participate in more social activities. It involves graded levels of the emotion (e.g. frustration, stress, or anger) and the student can determine if their level of emotion fits the thermometer during a specific situation.
Considerations for the intervention process specific to Ivan
Ivan should continue to be exposed in the general classes to continue engaging with other students and in different school environments. Other considerations will involve collaborating with the teacher(s), para, social worker, parent, and physical therapist for carryover. Interventions can be taken in place using both push in and push out, whatever best helps Ivan start building skills to achieve goals. The OT and OTA will work with Ivan individually and then slowly introduce in the classroom environment to generalize the skills he is learning. Best practices should always be used to ensure clinical reasoning, following all ethical principles and values to ensure the best education experience for Ivan.
Contribution of Occupational Therapist in the intervention process
The OTR/L will develop the goals and intervention plans while collaborating with the OTA to ensure both feel strong about the best interventions for the client. Throughout the intervention process, the OT will provide the appropriate supervision for the OTA as well as discuss modifications or changes to activities and interventions to reach the quarterly benchmarks and year goals. The OT will also continue to communicate with the rest of the IEP team to discuss continuation of therapy services for Ivan, changes in goals, etc.
Expectations of the Occupational Therapy Assistant involved in the intervention process
The OTA should be able to understand the evaluation results or ask questions to ensure they feel knowledgeable to take lead in the intervention sessions with Ivan. The OTA will also provide input on the intervention plan, observations made during the sessions, and modifications needed to meet Ivan’s needs and the team’s priorities. The OTA should also understand the team goals along with OT specific goals. If the OTA does not have the competency levels or has questions for therapeutic activities, they should reach out to the OT. The OTA should keep progress notes of the goals met during the Occupational therapy minutes.
Discharge Planning
Indicators that would prompt the IEP team to reduce/discharge direct OT services
OT services are no longer needed or should be reduced when Ivan starts achieving his OT related goals connected to fine motor, visual motor, writing skills and working at his grade level (or if we identified a different form for him to participate in class such as using a keyboard versus handwriting). Also, if environmental modifications are working well for Ivan, it might be good to shift to indirect forms of service delivery that way OT is still available for consult if anything changes. OT might also need to reduce or discontinue services when Ivan is not longer making therapeutic progress. We need to show continued progress to justify for continued therapy.
Ivan might be discharged from occupational therapy services if he is participating in all areas of his education experience (e.g. no longer need special education). Another scenario would be if the parents no longer want Ivan to get Occupational Therapy or if Ivan reaches the age of 21 and is transitioning out of school.
References
American Occupational Therapy Association. (2020). Occupational therapy practice framework: Domain and process (4th edition). American Journal of Occupational Therapy, 74(Supplement 2), 7412410010.https://doi.org/10.5014/ajot.2020.74s2001
Christiansen, C.H., Baum, C.M., & Bass, J.D. (Eds.). (2015). Occupational therapy: Performance,participation, and well-being (4th ed.). Slack, Inc.
Cole, M. B., & Tufano, R. (2020). Applied theories in occupational therapy: A practical approach (2nd ed.).Slack, Inc.
O’Brien, J. C., & Kuhaneck, H. (Eds.). (2020). Case-Smith’s occupational therapy for children and adolescents (8th ed.). Elsevier.
