Running head: CASE STUDY – SAMMY 1

Case Study: Sammy

Yara Bezgina, Megan Campbell, Jessica Fong,

Gerilynn Gobuyan, Meredith Petrillo, & Gayle Young

Touro University Nevada

CASE STUDY – SAMMY 2

Client Participation in Occupational Areas

Sammy is a 22-month-old male with low tone, cortical vision impairment (CVI), and

infantile spasms, making it difficult for him to participate in meaningful occupations without

moderate (Mod Ⓐ) or maximum assistance (Max Ⓐ). Sammy’s occupational areas of play,

activities of daily living (ADL’s) and instrumental activities of daily living (IADL’s) are usually

only completed if one of his parents helps to facilitate the activity. The most significant area of

occupation in Sammy’s life right now is play. He enjoys seeing bright lights and is able to

visually track bright lights. He enjoys his favorite toy, a brightly lit toy train, that also makes

noise.

Sammy enjoys playing with his train toys and other bright toys in supine or prone. He

also welcomes auditory and vestibular input, such as hearing music and being pushed on a

swing. In regards to ADL’s, Sammy enjoys eating and tolerates eating with a bottle or being

spoon-fed. Sammy has adaptive equipment in his home which includes a bath chair, a

wheelchair/stroller, and a stander. Since Sammy demonstrates poor trunk control and mobility,

his IADL’s are also affected. He cannot roll or move around without receiving Mod Ⓐ or Max

Ⓐ. In resting position, Sammy’s hands are in a fisted position with thumb adduction.

Since Sammy is 22-months-old, the occupational areas of work and leisure are not

applicable. Most of his educational and social experiences come from interactions with his

parents and brother. He is able to babble and he can imitate words such as “mama” or “baba”.

Upon request, Sammy also likes to blow kisses as a sign of affection. Social participation is

achieved through his interaction with Jerry, his four and a half year old brother, as well as

interactions with his mom, dad, and therapist. Sammy is fully functional in his occupational area

CASE STUDY – SAMMY 3

of sleep. He sleeps six hours a night, getting up intermittently for feeding. According to his

parents, Sammy sleeps approximately 12 hours a day.

Characteristics of Movements

Sammy experiences fluctuating muscle tone in his upper and lower extremities, and as a

result has difficulties completing his occupations. Sammy will attempt to work on grasping and

releasing if there is food involved. He enjoys sitting in his adaptive chair, which helps him to

work on trunk stability and head and neck control. Currently, he is working on hand to mouth

movement during feeding so that he can bring food to his mouth. Sammy is also practicing using

a sippy cup, which requires bilateral hand coordination, as well as Mod Ⓐ to bring the cup to his

mouth. In supported sit, he is able to extend his neck for about 30 seconds to hold his head

upright. When placed in prone with elbows propped, Sammy is able to extend his head and

visually track bright lights to both sides of midline. Sammy is unable to roll independently, and

demonstrates a fisted position with thumb adduction while in a resting state. When toys are

placed at midline, Sammy attempts to reach for the toys, but has trouble grasping them. If he

receives assistance in grasping the toys, he demonstrates difficulty with voluntary release.

Sensory Integration and Self-Regulation Issues

According to Keshner and Cohen (1989), testing the functionality of the vestibular

system can help indicate issues related to postural control. Sammy enjoys bright lights, sounds,

and vestibular input while playing. This suggests that he is hyporesponsive in a majority of his

sensory systems, and enjoys seeking sensory input whenever it is provided for him. Sammy’s

hyporesponsiveness to sensation could also be due to his developmental delays and CVI

diagnosis.

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The visual system also contributes to stabilizing responses. Sammy’s cortical vision

issues contributes to his postural control issues. Unexpected feedback interferes with the child’s

ability to respond appropriately. Therefore, therapy should be aimed at eliminating extraneous

stimuli and assisting Sammy’s parents in planning for a changing visual scene. Children with

visual deficits or who have difficulty compensating for unexpected or novel inputs will benefit

from an unchanging environment in the early stages of motor learning (Keshner and Cohen,

1989). Although Sammy is 22-months-old, he is developmentally behind in his early stages of

motor learning.

Assessment Tools

The first assessment that could be utilized is the Developmental Profile-3 (DP3). This

assessment is used for children between the ages of birth to 12 years old. This norm-referenced

test can help establish Sammy’s abilities within five domains: physical, adaptive behavior,

social-emotional, cognitive, and communication. The assessment is easy for the therapist to take

into the home and use with Sammy’s parents. Although Sammy is developmentally delayed due

to his diagnoses, this assessment will allow the therapist to determine Sammy’s level in many

aspects of his life and develop an appropriate intervention (Alpern, 2007).

Another assessment that can be used with Sammy is the Infant/Toddler Sensory Profile

(SP). This measure is norm-referenced and is appropriate for children from birth through 36

months. The form is filled out by the caregiver and takes approximately 15 to 20 minutes to

complete. The SP tests the following categories: general processing related to schedules and

routines, auditory processing, visual processing, tactile processing, vestibular processing and oral

sensory processing (Dunn, 2002). The SP can determine if Sammy is experiencing low

registration, sensation seeking, sensory sensitivity, sensation avoiding, or low threshold in any of

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the processing domains. This assessment will be especially important in order to determine if

Sammy is having difficulties in other areas of sensory processing aside from his visual

impairment. Sammy’s mother can easily fill out the assessment while the therapist works with

Sammy in the home (Dunn, 2002).

Lastly, the Hawaii Early Learning Profile (HELP) can be used to identify Sammy’s

needs, track his growth and development, and determine intervention objectives. This is a

criterion-referenced assessment for children birth to three-years-old and can be administered

periodically to track the progress of the child. The HELP is divided into seven domains including

regulatory/sensory organization, cognitive, language, gross motor, fine motor, social, and self-

help. Administration of the assessment is done by one or more interdisciplinary pediatric/early

childhood specialists (e.g., occupational therapist, teacher) who observe the child in multiple

settings; however, the natural environment is preferred (Parks, Furono, O’Reilly, Inatsuka,

Hoska, & Zeisloft-Falbey, 1994).

Functional Problem Statements

Sammy is unable to see in grey tone, from distances further than two and a half feet and has

issues with depth perception due to his cortical vision impairment.

Sammy is unable to sit independently due to poor trunk control.

Sammy is unable to grasp, release or produce in-hand manipulation of objects due to his

hands resting in a fisted position with thumbs in adduction.

Sammy is unable to bring food from hand to mouth due to his inability to cross at midline.

Sammy is unable to communicate with others due to poor control of his oral motor muscles

used for vocalization/verbalization.

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Family Goals

Sammy’s family is very concerned about his future. His family values independence as

they are from an American cultural background. The family would like to see Sammy improve in

five major areas. The first goal is to improve Sammy’s postural control and his vestibular

system. Communication is also another area in which his family would like to see change.

Sammy is almost 24-months-old; at 24 months, a child should have 25 single words within his or

her vocabulary (Case-Smith & O’Brien, 2010). Sammy currently babbles and has no spoken

words, but can imitate sounds such as “mama” and “baba”. The family wants Sammy to have as

much of a normal childhood as possible and would like him to be able to play with his older

brother, Jerry.

As Sammy ages, his family is concerned with his self-help abilities, more specifically

feeding. His family would like to see him participate more during the feeding process and be

able to feed himself during meal time. Finally, the family is concerned with Sammy’s visual

efficiency. The family would like to help Sammy adjust to his CVI issues and help Sammy

improve his vision skills as much as possible. Due to these family goals and concerns, the family

is seeking home-based occupational therapy (OT) services.

COAST Goals

The COAST method of writing goal statements for OT services was designed by Crepeau

et al. (Gateley & Borcherding, 2011), with the focus that practice should be client-centered and

occupation-centered. COAST is an acronym that considers the client, the occupation, the level of

assistance or independence, specific conditions pertaining to the client, as well as the desired

timeline in which the goal is expected to be accomplished (Gateley & Borcherding, 2011).

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COAST Goal 1: Sammy will visually track a bright toy train in a dark room with Mod Ⓐ (75%

verbal prompting) for at least 15 seconds by June 20th, 2013.

Objectives for COAST Goal 1

1. Sammy will play with a lightbox in a dark room using bright colored gel pads (Baker-Nobles

& Rutherford, 1995).

2. Sammy will visually tracking a brightly lit up flashing train toy in a dim lit room while in

supported sitting.

Activities for COAST Goal 1

1. Sammy will visually track a bright toy train in a dark room.

2. Sammy will work on feeding techniques while sitting on his mother’s lap using a Glow

cutlery set. (Swift, Davidson, & Weems; 2008).

3. Sammy will play with high contrast colored LEGO Duplos (e.g., red and yellow) on top

of a black-colored board while in supported sitting.

4. Sammy and Jerry will make shapes with Softee Dough of contrasting colors while

Sammy is in his stander.

COAST Goal 2: Sammy will engage in supported sit with Mod Ⓐ (50% physical prompting)

during bathing, play, and feeding activities for at least 5 minutes by June 20th, 2013.

Objectives for COAST Goal 2

1. Sammy will sit with support on the floor with his brother in order to play with toys for at

least five minutes with Mod Ⓐ (50%).

2. Sammy will sit with Mod Ⓐ in the bathtub for at least five minutes in order to be washed and

play with bath toys.

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Activities for COAST Goal 2

1. Sammy will lay in prone on a Happy Flyer Tummy Time while playing with his trains.

2. Sammy will play in supported sit and reach for toy trains located off to his right or left

side.

3. Sammy will sit in the hammock hung in his backyard and be pushed gently by his

parents.

4. Sammy will participate in oral motor exercises (e.g., blowing bubbles) to strengthen his

facial muscles while sitting with his mother in supported sitting.

COAST Goal 3: Sammy will learn to grasp toy trains, sippy cups, and food items with both

hands (Mod Ⓐ, 50% hand over hand assistance) while wearing a thumb abduction splint by June

20th, 2013.

Objectives for COAST Goal 3

1. Sammy will grasp a lightweight bright toy train with the help of his thumb abduction splint

while sitting on the floor.

2. Sammy will pick up food with his fingers and bring it to his mouth Ⓘ (50%) of the time.

Activities for COAST Goal 3

1. Sammy will finger paint with a variety of baby food in order to facilitate thumb

abduction.

2. Sammy will lay prone on a Happy Flyer Tummy Time and play with lima beans in a

plastic container placed six inches in front of him.

3. Sammy will stack one inch blocks with hand over hand assistance while in supported sit.

4. Sammy will read a children’s sing-along-book with his brother and his father, while

receiving hand over hand facilitation in turning pages and pressing buttons on the book.

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Treatment Session Utilizing Occupational Therapy Goals and Objectives

According to Kellegrow (2008), creating an intervention based off of a family interview

and daily occupations of the family helps to create a family-centered approach to therapeutic

intervention. According to Part C of IDEA (Case-Smith & O’Brien, 2010), all early intervention

programs for children under three years of age should occur in a natural setting. Treatment

should be in the natural environment and should be as intrinsically motivated as much as

possible.

In reference to the first COAST goal, Sammy will play with a brightly lit toy train that

makes noise to facilitate engagement in play occupation while strengthening core muscles to

facilitate postural control during upright sitting. Utilizing a moving toy train with bright colored

lights and sounds will help motivate Sammy to visually track the toy. As OT progresses, Sammy

will be encouraged to flex his neck while lying supine by showing him a toy; at the same time,

the therapist will plantar flex Sammy’s ankles to stimulate opposed muscles at opposite ends of

the body. OT intervention will occur at the same time of day in the same location of the house.

When addressing postural control, treatment should occur in a consistent environment to provide

reliable and predictable feedback (Keshner & Cohen, 1989). Once postural control has been

achieved, the therapist can grade the activity up by treating Sammy in different areas of the home

at different times of the day.

In reference to the second COAST goal, Sammy will engage in play activities while in

supported sit or in prone. The therapist will incorporate various equipment to improve Sammy’s

postural control and to develop a stable base of support. By engaging in activities with his

brother and parents, Sammy will participate in two areas of occupation: play and social

participation. To help motivate Sammy’s participation in play, the therapist will utilize Sammy’s

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favorite toys and involve his brother, Jerry, in the activity. Sammy’s parents can help facilitate

play time with bubble-blowing activities to strengthen Sammy’s facial muscles. A hammock

swing will be set up in Sammy’s backyard to provide Sammy with vestibular and proprioceptive

input and work on his postural control. Sammy’s parents will gently move him back and forth

while he sits or lies in prone extension in the hammock swing.

Lastly, the therapist will address the third COAST goal by creating a personalized spica

thumb abduction splint for Sammy. When engaging in play and feeding activities, Sammy will

wear the thumb abduction splint to assist in grasping objects. Sammy will engage in a finger

painting activity with the therapist, utilizing his fingers or a square sponge to facilitate thumb

abduction. To engage his upper body and develop his physical skills as well as muscles for

rolling over, sitting, and crawling, Sammy will lie prone on the Happy Flyer Tummy Time while

attempting to grasp lima beans located in a plastic container placed six inches in front of him.

Sammy will work on grasp and release by stacking one-inch blocks with hand over hand

assistance. Utilizing food to intrinsically motivate Sammy will help facilitate his fine motor

pincer grasp and improve the tone in his thumbs.

SOAP Note

The problem-oriented medical record (POMR) was developed in the 1960s by Dr.

Lawrence Weed to standardize physician and nursing documentation (Gateley & Borcherding,

2011). As part of a client-centered approach to documentation, Weed recommended that the

POMR be organized into four sections. Thus, the SOAP note was introduced to define four

distinct sections: subjective, objective, assessment, and plan. The subjective section includes the

client’s reports on his or her own problems, needs, and perception of progress. The objective

section contains the health professional’s observation of the client’s performance and the

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treatment provided. The assessment section is the analysis and interpretation of events reported

in the subjective and objective section. Finally, the plan section involves the anticipated

frequency and duration of services (Gateley & Borcherding, 2011).

Subjective : Sammy’s mother reports that he is easily engaged with bright colored or musical

toys, and enjoys sitting in his adaptive chair. Mom reports that he responds with smiles to verbal

cues and changes in tone of voice. Sammy started receiving in home OT services one month ago.

Mom also noted that Sammy’s favorite toy is a light-up, colorful train.

Objective : Sammy engaged in 1 hr of OT at home, focusing on postural control, visual-motor

skills, and fine motor skills (grasp, in-hand manipulation, and shifting). Preparatory activity (oral

praxis) included a bubble-blowing game. This was followed by a self-feeding activity, while

standing and using adaptive chair.

Visual-Motor: Sammy was placed in his stander while playing Softee Dough with Jerry.

He tolerated being in his stander for 8 minutes. Sammy especially liked the red and blue

Softee Doughs and enjoyed touching and examining the dough.

Postural Control: Sammy required Mod Ⓐ to lie prone on his Happy Flyer Tummy Time

for 8 minutes. He demonstrated fair postural control and energy levels required for

reaching and grasping his bright toy trains and displayed Min fatigue. Sammy required

Min prompts and cues with Mod Ⓐ when blowing bubbles in supported sit with his

mother.

Grasping: Sammy spent 20 minutes in adaptive chair during feeding. With HOH Ⓐ,

Sammy demonstrated Ⓘ reaching for raspberries 4 out of 6 trials. Sammy struggled but

showed gradual improvement. Sammy was able to grasp raspberries I 3 times out of 6

and bring raspberries to mouth with Mod Ⓐ. Sammy was able to maintain balance,

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showed good stability and postural control while sitting in adaptive chair. Sammy

showed good motivation and interest to continue with the activity and expressed his joy

by laughing and smiling. Sammy showed interest and joyfulness during feeding. Sammy

likes food and shows good motivation to participate in activities related to self-feeding.

Assessment : Sammy had problems with grasp and release, as evidenced by fisted hand position.

He wears a thumb abduction splint to facilitate functional grasp. Sammy has difficulty crossing

midline as evident by the child not being able to bring food to his mouth. Fluctuating muscle

tone and delayed motor planning impairs Sammy’s ability to self-feed Ⓘ. After feeding, Sammy

showed improved ability to grasp food with his fingers utilizing thumb abduction splint. Sammy

showed better ability to balance himself in the chair while reaching, and showed motivation to

Ⓘreach and grasp. Sammy attempted to bring food to the mouth. Sammy has a good potential to

follow tactile facilitation and cues. Sammy demonstrates good potential to improve his fine

motor skills and postural control through participation in play activities.

Plan : Sammy will meet with OTR @ home 2x/wk, 1 hr/session over 2 mos to address self-

feeding, postural control, and visual motor skills. Sammy will work on sitting, grasping, and

holding a sippy cup and bringing it to his mouth. Sammy will work on fine motor coordination

by playing with different-sized toys in his play area. Sammy will work with SLP on

communication skills. Sammy’s family will encourage and motivate Sammy to learn and utilize

appropriate skills for ADL’s.

Post-Discharge Environment

It is important to consider the most natural setting for the child when planning the

discharge environment. As Sammy is only 22-months-old and is currently receiving treatment in

his home, the home will continue to be the environment that Sammy spends the majority of his

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time. Providing consultation to Sammy’s parents in regards to achieving an optimal level of

independence throughout his life is also a crucial aspect to consider.

First, Sammy’s parents will receive information on how to balance and schedule their day

in order to create opportunities for intrinsic motivation throughout the day. His parents will

receive education on how to provide therapeutic play to their child to facilitate developmental

milestones without burning themselves out. Based on his family’s schedule and Sammy’s needs,

it is recommended that the OT continue to help organize a schedule for the family where each

family member can contribute to therapeutic play and activities thus removing caregiver strain. If

need be, parents may be eligible to receive respite care services, and the OT will make

recommendations for this if it seems appropriate in the future.

Sammy’s parents will be taught an array of games and play activities that involve the

entire family; this will facilitate Sammy’s independence and foster a more cohesive feeling of

being a family. To achieve these goals of independence and cohesiveness within the family unit,

Sammy’s parents will be encouraged to observe Sammy during his OT sessions, and an

explanation will be provided to his parents in regards to theoretical models supporting the

therapy plan. Sammy’s family should be integrated into the treatment sessions when appropriate

to encourage collaborative play and inclusion within the family.

Safety is of the utmost importance when considering pediatric intervention plans.

Sammy’s parents have experience raising his older brother Jerry, and therefore are aware of

some of the basic safety issues that need to be in place in order to provide Sammy with the safest

environment possible. Besides the safety concerns of a typically developing child, additional

safety measures must be in place for Sammy. One of the most critical potential safety hazards for

Sammy is his low vision due to his CVI. Sammy’s parents must be aware of potential hazards

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that a typically developing child would be able to see and must make sure that Sammy is safe

from these hazards. Once he becomes more mobile and independent in locomotion, Sammy’s

parents will have to be aware of the layout of their household, and make sure that Sammy does

not bump into furniture. They will also have to ensure that Sammy does not have access to sharp

objects or items that might burn, puncture, or otherwise injure Sammy. In concurrence with

safety precautions, it will be essential to maintain Sammy’s dermatological function splint care,

and an application schedule will be discussed and approved with parents.

In order to keep Sammy’s natural environment conducive to locomotive patterns,

surfaces and furniture should be sturdy in nature and in place for Sammy to hold on in order to

facilitate creeping and walking. Furniture may need to be rearranged to promote the most

movement and safest environment for Sammy’s limited vision. Musical and visually stimulating

toys are recommended to increase his motivation to creep and engage in supported walking.

At home Sammy will be able to participate more effectively in social interactions if he

can see, hear, reach and touch therapeutic items such as symbolic representations of letters, toys

with different textural components and a communication board. These items should be accessible

and within reach, and Sammy will be encouraged by family members to use them as often as

possible.

Sammy’s brother Jerry should participate in play activities as much as possible, which

can be therapeutic in nature as play can be a modality for change to the young child. Sammy’s

brother is a typically developing child, and will help Sammy with his social skills by modeling

socially appropriate behaviors. Occupational therapy should be family-centered and focus on

games and activities that the two siblings can enjoy doing together.

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All future interventions should be as intrinsically motivating as possible for Sammy.

Interventions should also be done with objects and items that the family has in the home as

much as possible. Simple exercises, such as blowing cotton balls with straws across the room

or playing a cup game with marbles, could help address Sammy’s fine motor issues and cortical

vision deficits. The occupational therapist will continue to facilitate these interventions in order

for Sammy to be as independent as possible throughout his life.

Recommendations

Sammy’s parents and therapists should begin to plan the transition from home to a

special education or regular preschool classroom within the next 12-15 months. The focus should

emphasize developmental milestones and pre-academic skills in order to be able to participate in

the preschool environment. Sammy’s service coordinator for his Individual Family Service Plan

(IFSP) will help manage the transition from home-based early intervention to the school

environment when Sammy is old enough.

Sammy’s parents should keep the play environment simple and uncluttered. This will

also ensure that Sammy can safely explore his environment without being injured. Sammy’s

parents should ensure the home is free of obstacles and any harmful household products that

Sammy may not be aware of due to his CVI (Good, 2001). Additionally, it is recommended that

the family use different lighting situations to reach optimal conditions for viewing. Items that

Sammy uses on a regular basis should be safe, hygienic, high contrast, and easy to view.

Although Sammy has not experienced spasms for the last six months, it is recommended

that he begin a medication treatment consisting of oral prednisone (liquid form) if the spasms

were to reoccur. Historically, daily injections of adrenocorticotropic hormone (ACTH) have been

the first choice of treatment for infantile spasms (Kossoff, Hartman, Rubenstein, & Vining,

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2009). However, ACTH has been associated with adverse side effects and costly. Oral

prednisone is a better alternative to ACTH due to its affordability and is less invasive than daily

injections (Kossoff et al, 2009). To keep Sammy on a consistent medication schedule, his parents

should use a visual schedule to track his medication times and medical appointments. This will

ensure he is receiving consistent and proper medication to treat his spasms, and will contribute to

his performance during OT. Since Sammy’s spasms and CVI are a result of a neurological defect

and damage to his nervous system, his parents should be diligent about keeping appointments

with a pediatric neurologist, pediatric ophthalmologist, as well as a developmental pediatrician.

Sammy’s parents should track his progress with the medications he takes for his spasms.

Further home-based OT treatment is recommended to prepare the child for preschool

transitioning and to help Sammy reach developmental milestones. A typically developing child

will know approximately 25 words by the time he or she reaches 22 months (Case-Smith &

O’Brien, 2010). Since Sammy is only babbling and attempting a couple of words,

communication is another aspect of significance and concern with Sammy. According to Kaiser

and Roberts (2011), delayed speech and language are early indicators of developmental deficits

that may impact future academic and social success. Early intervention should focus on pre-

linguistic forms of communication to increase the child’s communication abilities if the child

demonstrates a need for this form of therapy (Kaiser & Roberts, 2011). Activities such as

blowing bubbles and mimicking facial expressions provide physical and sensory input prior to

language stimulation. Sammy might be demonstrating inability to communicate due to poor

musculature of his muscles of facial expression (Kaiser & Roberts, 2011). Strengthening these

muscles will aid Sammy and his family in their overall communication goals for him. A speech

language pathologist and an augmentative and alternative communication specialist (AAC) can

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provide recommendations to evaluate communication strategies to incorporate into Sammy’s

daily routine.

A vision specialist can assist Sammy in implementing visual interventions, especially as

Sammy is preparing to transition into school. Sammy’s parents and brother should continue to

encourage and help Sammy in achieving goals and milestones associated with his ADL’s and

IADL’s. Sammy’s service coordinator for his IFSP can help to coordinate the therapeutic

interventions from his vision specialist as well.

Sammy should receive an IFSP, part C of IDEA. Interventions should occur in a natural

environment, identify family priorities, and provides timely, comprehensive, and

multidisciplinary evaluations. The IFSP is a written plan that delineates families’ plans and

provides services, and is reviewed every six months, with an annual reevaluation. A service

coordinator is assigned to oversee and manage the implementation of the IFSP. Transition

procedures are implemented through three years of age. As the family is the main priority in this

intervention, preparing Sammy for preschool and discussing the IFSP is relevant and appropriate.

Justification for Treatment

Self-care activities are one of the primary goals for early intervention as children are

learning the necessary skills in order to gain independence from their parents in their ADL’s.

According to Kellegrew (1999), participation in self-care activities depends on two primary

components: ability and opportunity. The opportunity to perform self-care is as important of a

contributor to learning self-care as the ability to perform the task. For very young children, the

saliency of the environment and developmental milestones are key features in developing

opportunities to perform these tasks (Kellegrew, 1999). In early intervention, it is vital to create

therapy goals centered on family values and goals that utilize the child’s intrinsic motivation.

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Swift, Davidson and Weems (2008) also encourage active learning and intrinsic motivating and

rewarding stimuli.

Another justification for the inclusion of the family in the overall treatment according to

Humphrey, Jewell, and Rosenberger (1995) is the dynamical systems perspective. This

perspective correlates with various fine motor skills and emphasizes creating opportunities for

practice when the therapist is not present. Important factors to consider when facilitating fine

motor skills include object size, ease of instructions, and having an adult model the skills

(Humphrey, Jewell & Rosenberger, 1995). By having Sammy work on grasp and release of

various objects with a skilled therapist, he will be able to model the correct grasp patterns. After

his therapeutic sessions, Sammy should be given multiple opportunities to practice these skills at

home with his family. Sammy has better opportunities to achieve future independence and

success in the goals that have been set by his family if he is given these opportunities.

To aid Sammy in his gross motor skills, it is important to consider the vestibular system’s

influence on postural control (Keshner & Cohen, 1989). There is consensus in the literature that

responses to whole-body destabilization are influenced by visual, proprioceptive, and vestibular

input (Keshner & Cohen, 1989). By utilizing a Happy Flyer Tummy Time with support from the

therapist, Sammy can work on postural control while receiving vestibular stimulation. When

treating a child with postural instability, it is important to assist the child in planning a motor

response pattern through prior information about task demands. Additionally, motor response

should be supported through graded stimulation of functionally opposed muscles. By adding a

toy for Sammy to reach and grasp, his feedback loop will be enhanced due to specific sensory

input (Keshner & Cohen, 1989).

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The therapist who develops interventions for a child with CVI should present the child

with different options and be cognizant of selecting safe, appropriate, and interesting stimuli

(Swift, Davidson, & Weems, 2008). Children with CVI may have a wide range of visual

impairments including fields of visual loss and fluctuations in overall performance. Interventions

should simplify the visual environment while avoiding extraneous stimuli and visual

bombardment. Swift, Davidson, and Weems (2008) also suggest decreasing brightness and glare

in the therapeutic environment to avoid light sensitivities. In Sammy’s case, therapy could be

conducted in a dim lit room. The therapist will use the light up train, as this is Sammy’s favorite

toy, which will stimulate Sammy’s visual system. Using toys that children are familiar with

provides therapeutic benefits since children attend to these objects more positively (Swift,

Davidson & Weems, 2008). Interspersing therapy in different lighting environments will assist

Sammy in his occasional fluctuation in visual performance due to his CVI.

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References

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Case-Smith, J., & O’Brien, J. (2010). Occupational therapy for children (6th ed.). St. Louis,

Missouri: Mosby Elsevier.

Coppard, B.M., & Lohman, H. (2001). Introduction to splinting: A clinical-reasoning and

problem-solving approach (2nd ed.). St. Louis, MO: Mosby.

Dunn, W. (2002). The infant/toddler sensory profile manual. San Antonio, TX: The

Psychological Corporation.

Gateley, C.A., & Borcherding, S. (2011). Documentation manual for occupational therapy:

Writing SOAP notes. (3rd ed.). Thorofare, NJ: Slack Inc.

Good, W. V. (2001). Development of a qualitative method to measure vision in children with

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