Running head: RUBY: A CASE STUDY OF A SIX-YEAR-OLD GIRL 1

Ruby: A Case Study of a Six-Year-Old Girl

Elisa Dick, Jacques Kriel, Devina Robinson, Breanne Rowland, Michael Yarvi, & Steve Young

Touro University Nevada

RUBY: A CASE STUDY OF A SIX-YEAR-OLD GIRL 2

How does this client participate in the 8 occupational areas? Consider the client’s age and

condition.

Ruby is a 6 year old child diagnosed with developmental delay and suspected of having

ADHD. The client is experiencing difficulties in almost all of her areas of occupation.

ADLs

Ruby is able to feed herself independently, however she frequently chokes and needs

reminders to chew. Ruby receives a blended diet at school due to the choking hazard. She is fully

independent in undressing but requires assistance in donning her shoes and socks, brushing her

hair and teeth, tying her shoes, and washing herself while bathing. She is able to button and

unbutton medium sized buttons and is able to zip a zipper. The client has poor safety awareness

which limits her ability to do some ADLs without supervision. She also has absent seizures

whenever she is extremely fatigued or ill, creating a safety concern, requiring supervision during

bathing.

IADLs

Client has difficulty in communication management due to her writing difficulties and in

community mobility due to her fatigue.

Rest and Sleep

The client has significant sleep problems and she must use medication or she only sleeps

2-3 hours a night.

Education

Ruby is in a typical class but is frequently in trouble for not paying attention and states

that she can't focus. Ruby’s fine motor difficulties cause substantial problems meeting the

activity demands of the educational environment. Ruby has difficulty with writing due to poor

RUBY: A CASE STUDY OF A SIX-YEAR-OLD GIRL 3

grasping patterns which results in fatigue. However, using a gripper does help decrease her

fatigue by correcting her grip. Her poor visual discrimination causes her to be unable to write

within the lines on a piece of paper; thus, adaptations such as highlighting the line allow her to

improve her handwriting because she can see where she is supposed to be writing. Ruby has

difficulty with bimanual coordination as is evidenced by her difficulty with cutting. She also has

poor visual memory resulting in her inability to complete many classroom tasks from memory.

The client cannot visually track a moving item across midline and has a convergence problem,

which leads to difficulty with visual attention in the classroom. She also lacks problem solving

strategies, motor skills, and visual perceptual skills to complete things such as puzzles.

Work

A six-year-old does not typically engage in work; thus, this area of occupation is not

applicable.

Play

Ruby cannot ride a bike without supervision and can only ride on the grass because her

seizure disorder causes a safety risk. Furthermore, Ruby’s fatigue limits her ability to engage in

prolonged play with peers. Ruby’s play is also limited by her constant referencing of her

imaginary friend, isolating her from playmates.

Leisure

Many children her age enjoy reading, drawing, and watching TV for leisure. However,

Ruby’s fatigue, poor visual perceptual skills, and poor fine motor skills interfere with Ruby’s

ability to participate in these leisure activities. Furthermore, many six-year-olds participate in

extracurricular activities, but Ruby has difficulty participating in structured leisure activities due

to her inattention.

RUBY: A CASE STUDY OF A SIX-YEAR-OLD GIRL 4

Social participation

The client’s constant references to her imaginary friends interfere with her ability to

make real friends. The client has difficulty focusing at school. Ruby uses her imaginary friend to

help her complete tasks. The client gets easily fatigued which interferes in her ability to

participate in the gross motor play that is typical of children her age which could isolate her from

her peers.

Briefly describe the characteristics of movement, postural reactions, and/or reflexes that

are of particular importance of this client.

Ruby is able to walk independently; however, she has a gait abnormality, being addressed

in physical therapy. Client becomes easily fatigued when walking long distances interfering with

her ability to participate in the community. Client’s fatigue and poor bimanual/bilateral

coordination significantly interferes with her occupational performance in all areas of

occupation.

Briefly describe any sensory integration or self-regulation issues that relevant to this client.

The client has significant sensory integration and self-regulation issues that result in

difficulty engaging in occupations due to an inability to properly regulate her system or to

perceive/process the sensory information in the environment. The client has been found to have

definite differences in: sensory seeking, emotionally reactive, low endurance/tone,

inattention/distractibility, sensory sensitivity, auditory processing, visual processing, vestibular

processing and touch processing. Additionally, sensory processing related to endurance/tone,

multi-sensory processing, body position and movement, movement affecting activity level,

sensory input affecting emotional responses, visual input affecting emotional responses and

RUBY: A CASE STUDY OF A SIX-YEAR-OLD GIRL 5

activity level, and emotional/social response delays were indicated. The client has also been

found to have a probable difference in poor registration and oral sensory processing. The client

would not tolerate a visual exam. Furthermore, the client has been found to be delayed in visual

discrimination, form constancy, sequential memory, and visual closure. The client has been

found to be advanced in visual memory, spatial relation, and figure ground. The client becomes

easily fatigued during visual tasks. Ruby also has difficulty in spatial relationships and motor

planning when drawing and presents with a one year delay in her drawing ability.

What assessment(s) will you use to evaluate this child?

Prior assessments were completed in order to identify potential concerns and difficulties

in Ruby’s ability to process sensory information and visual perceptual skills correctly. Ruby’s

mother completed the Sensory Profile questionnaire to help identify possible concerns regarding

the inability to process sensory information. The Test of Visual Perceptual Skills, 3rd edition,

specifically measured non-motor visual perceptual skills. Based on the results of these

assessments, we thought that feeding was important because of the need of nutrients for the body

to function in all motor and cognitive tasks. These results also indicate the most significant

cognitive delays in visual discrimination, as well as form constancy, and visual closure-which

should be alleviated due to our approaches of an obstacle course and other visual motor tasks that

have been recognized in the literature.

The Vineland Adaptive Behavior Scales, Second Edition will be used in order to measure

Ruby’s adaptive behavior in different environments. Ruby has many concerns and the test will

help determine her strengths and weaknesses, and the amount and types of assistance needed.

Due to Ruby’s difficulties with swallowing and inability to adequately break down food,

a modified Barium swallow study is required. Before we can begin working on feeding it is

RUBY: A CASE STUDY OF A SIX-YEAR-OLD GIRL 6

imperative that we know it is safe to do so. A modified barium swallow will give us more

information about what types of foods are safe for Ruby to eat.

To most efficiently teach the child skills that will help her remediate the delays that she

experiences, a form indicating a child’s type of learning (Learning4Life) should be determined

prior to treatment. This can be done using a test that is typically used for kids her age. It has age

appropriate wording and is easy and quick to administer. Ruby is also having reading difficulty

which causes her difficulty meeting educational goals. Because so much information in school is

presented visually it would be helpful for Ruby to have information presented to her in her

preferred learning style.

List five functional problem statements (You can assume some of these based on the

information provided in the case study.)

1. Client requires assistance to complete interlocking puzzles due to poor motor planning

2. Client is unable to complete many classroom tasks from memory due to a poor visual memory.

3. Client is unable to write within the lines on a piece of paper due to poor visual discrimination.

4. Client becomes easily fatigued which results in her inability to participate with peers and in

the community.

5. Inability to visually track across midline limits client’s ability to visually attend in the

classroom.

6. Client requires assistance to don her shoes onto the correct feet, don her socks, brush her teeth

and hair, tie shoes, and wash her body due to poor bilateral coordination and low muscle tone.

List five family/caregiver/child goals

1. Client will eat independently without verbal cues while chewing in order to break down her

food properly.

RUBY: A CASE STUDY OF A SIX-YEAR-OLD GIRL 7

2. Client will participate in group activities for 30 minutes without referencing of imaginary

friends 3/5 consecutive days.

3. Client will complete an interlocking puzzle independently 4/5 trials.

4. Client will maintain a seated position at desk for 15 minutes with 2 or fewer verbal cues 4/5

attempts.

5. Client will independently brush her hair and teeth 3/4 attempts.

Goals, Objectives, and Activities

Goal 1. Ruby will improve oral motor skills to safely chew and swallow a peanut butter and jelly

sandwich with 2 verbal cues or less by 6/22/2013.

Objective 1. Ruby will show improved oral motor strength by eating soft fruit safely

independently while seated during mealtime by 3/15/2013.

Activities:

1. Webber Oral motor practice cards

2. Chew art from cold cuts, cheese slices, and apple slices

Objective 2. Ruby will demonstrate safe chewing awareness by playing Foodland, a modified

version of Candyland with foods corresponding to each colored space.

Activities:

1. Bolus bag to chew different foods and identify how many chews that food

needs to be safe to swallow.

2. Organize food cards into difficult, medium, and easy to chew.

Goal 2 : Ruby will be able to independently select a matching outfit from her closet within a five-

minute time frame by 6/22/ 2013.

Objective 1: Ruby will complete an obstacle course including retrieving a ball based on color cue

RUBY: A CASE STUDY OF A SIX-YEAR-OLD GIRL 8

from the ball pit, crawling through the barrel, and throwing the ball in the appropriate colored

bucket to work on visual perceptual skills with 4 verbal cues by 5/20/2013.

Activities:

1. Find the stuffed animal from the ball pit.

2. Find the difference between between pictures.

Objective 2. While seated at the table, Ruby will replicate a 4-6 block pattern made by the

therapist using square blocks to work on form constancy independently 3/5 trials by May 1.

Activities:

1. Matching worksheet for form constancy.

2. Match wooden shape blocks to corresponding shape cards

Goal 3: Ruby will complete a 6-piece seated at a table to work on staying on task with fine motor

activities independently by 5/22/2013.

Objective 1: Ruby will work on fine motor skills by forming the letters of her name in

Theraputty 3/4 trials while seated at a table with 1 verbal cue by 5/10/2013.

Activities:

1. Ruby will create tissue paper art by writing a word of her choice with glitter

glue, then placing tissue paper on the glue using training chopsticks.

2. Making paper chains.

Objective 2: Ruby will stay on task and work independently to complete a maze seated at the

table with auditory distractions by 3/15/13.

Activities:

1. Simon Says

2. Skillstreaming Lesson 10 “Ignoring Distractions”

RUBY: A CASE STUDY OF A SIX-YEAR-OLD GIRL 9

Treatment Plan

Ruby will participate in a one-hour treatment session in an outpatient clinic. The therapist

will utilize a client-centered and family-orientated approach to address the needs of Ruby.

Various activities were selected to take into account the goals of the family, along with play-

driven activities incorporating Ruby’s interests. The therapist selected tasks that could be

transferred to other environments that are also prominent in Ruby’s life, such as school and

home. The overall goals of the treatment plan were devised with the hopes of improving a

variety of aspects of Ruby’s life specifically focusing on feeding skills, attention, and visual

perceptual skills.

Goal 1: Ruby will complete a 6-piece puzzle in a seated position at the table to work on staying

on task with fine motor activities independently by 5/22/2013.

Objective 1-: Ruby will work on fine motor skills by forming the letters of her name in

Theraputty 3/4 trials with one verbal cue by 5/10/2013.

Activities:

1. Tissue Paper art- Therapist will instruct Ruby to create tissue paper art by writing a word of

her choice and then placing tissue paper squares on the glue using training chopsticks.

2. Making paper chains- Therapist will fold a 8.5 X 11 size paper four times horizontally, then

draw half of a shape. If Ruby feels comfortable have her draw shape. Therapist will then instruct

Ruby to cut out shape with child safe scissors..

Objective 2: Ruby will be able to independently complete a maze seated at a desk with auditory

distractions while staying on task by 3/15/13.

Activities:

1.Simon Says Game-Therapist will stand five feet away facing Ruby instructing her to do

RUBY: A CASE STUDY OF A SIX-YEAR-OLD GIRL 10

perform various gross motor and fine motor movements. One out of every five instruction should

be an attention based activity. IE “Simons says to sit and draw a picture of your favorite animal”.

2. Skillstreaming Lesson 10 “Ignoring Distractions”

The therapist will help Ruby identify why she needs to know how to ignore distractions. The

therapist will then teach Ruby the steps to ignoring distractions. These steps are:

Step 1: Count to 5.

Step 2: Say to yourself "I won't look I'll keep working".

Step 3: Continue to work.

Step 4: Say to yourself "Good for me. I did it."

The therapist will model using the skill at home, at school, and in the community while Ruby

tries to distract the therapist. Ruby will then role play using the skill at home, at school, and in

the community while the therapist tries to distract her. The therapist will then provide Ruby with

feedback on her performance.

Goal 2: Ruby will be able to independently select a matching outfit from her closet within five

minutes by 6/22/2013.

Objective 1: Ruby will complete an obstacle course including retrieving a ball from the ball pit,

based on color; crawling through the barrel; the dropping the ball in the appropriate colored

bucket to work on visual perceptual skills with four verbal cues by 6/20/2013.

Activities:

1. Ruby will retrieve various small stuffed toys from ball pit. Using the plastic ball pit, the

therapist will hide stuffed animals while Ruby hides her eyes. Ruby will start five feet away and

be instructed to find the animal and bring it back. This will be a timed task. Therapist will have

Ruby perform three repetitions of this task using large to small sized stuffed toys to increase

RUBY: A CASE STUDY OF A SIX-YEAR-OLD GIRL 11

difficulty.

2. Find the difference between pictures. Ruby will be seated at a desk with therapist seated next

to her. Therapist refers to Mardi Gras Time activity book beginning on page 12, having Ruby

identify five differences in the pictures. Continue with three of the same activities throughout the

book.

Objective 2: While seated at the table Ruby will replicate a 4-6 block pattern laid out by therapist

using square blocks to work on form constancy independently 3 out of 5 trials by 5/1/2013.

Activities:

1. Matching worksheet-Ruby will be seated at a desk with therapist seated next to her. Therapist

will refer to page 11 in Mardi Gras Time workbook and have Ruby complete the activity.

2. Match shape blocks to shape cards- Ruby will be seated at a desk with therapist seated across

from her. Therapist will place three wooden blocks on desk in front of Ruby and instruct her to

“match the shape of the card with the block”. Therapist will perform this three times increasing

block number 3, 5, 7. Therapist will record time it takes to complete task.

Goal 3: Ruby will improve oral motor skills to safely chew and swallow a peanut butter and jelly

sandwich with two verbal cues by 5/22/2013.

Objective 1: Ruby will show improved oral motor strength by eating soft fruit safely and

independently by 3/15/2013.

Activities:

1. Webber Oral motor practice cards- Therapist will have Ruby complete five oral motor practice

cards.

2. Chew art from cold cuts, cheese slices, and apple slices- Therapist will instruct Ruby to bite

into various foods and create different patterns with her teeth marks.

RUBY: A CASE STUDY OF A SIX-YEAR-OLD GIRL 12

Objective 2: Ruby will demonstrate safe chewing awareness by playing “Foodland” for 10

minutes with less than four verbal cues by 5/7/2013.

Foodland is a version of Candyland where player eats a food corresponding to square color.

1. Therapist will instruct Ruby to chew various foods using a bolus bag and identify how many

chews that food requires to be swallowed safely.

2. Organize food cards into difficult, medium, and easy. Therapist will give Ruby 10 cards with

various foods on them and instruct her to place the food into the appropriate pile based on how

hard it is to chew.

Occupational Therapy SOAP Note

Occupational Therapy SOAP Note

Date: 3/15/2013 Time: 1:00pm

Subjective. Client complained of having difficulty focusing while at school, mother believes this

could be related to ADHD. Client’s mother reports of difficulty with chewing and feeding during

meals, explaining that client does not chew her food enough. Client said she was tired because

she didn’t sleep last night and had little interest in participating in any activities.

Objective . Client participated in a 60-minute OT session in outpatient clinic focusing on

attention span, chewing/eating and visual perceptual skills.

Attention Span- Client participated in a 20-minute fine motor and attention based activity

requiring continuous verbal cuing to remain on task. Client periodically expressed frustration

with inability to perform certain fine motor movements involving bilateral coordination and

particular shape discrimination. Client demonstrated the ability to independently stay on the task

for ~5 minute periods, then needing a 30 second break.

Chewing/Eating- Client participated in a 20-minute oral-motor exercise activity focusing on

RUBY: A CASE STUDY OF A SIX-YEAR-OLD GIRL 13

chewing, swallowing and cheek/tongue ROM. Client specifically showed difficulty in oral-motor

function involving tongue ROM. Client demonstrated limited rotary chewing involving hard

table foods only swallowing ~25%. Client needed 2-3 verbal cues to sufficiently swallow soft

table foods. Client demonstrated the awareness for the need to chew various textures longer than

others.

Visual Perceptual- Client participated in a visual discrimination activity needing 1-2 verbal cues

to complete the task of finding a stuffed animal in the ball pit. When performing an attention

based visual discrimination task in an activity book, client needed 2-3 verbal cues to find the

differences in pictures.

Assessment: Client demonstrated problems with attention span which will affect her success in

school. Client also displayed problems with chewing foods sufficiently, resulting in safety

concerns with independent feeding. Visual perceptual skills are an area of concern, particularly

with visual discrimination, sequential memory, form constancy, and visual closure. These

problems will affect client’s performance at school and completing ADLs. Client has shown

improvement in visual discrimination skills, requiring less verbal cueing to complete activities in

book. Improvement has been shown in eating skills as client has recognized the need to chew

harder texture foods more than soft textured foods. Client will benefit from continued OT

services which challenge her selective attention abilities. OT services will help improve her

visual closure skills, form constancy and sequential memory. These skills will benefit her overall

academic performance in school.

Plan: Ruby will continue to receive OT treatment 2x/wk for one hour, to improve attention,

chewing/eating and visual perceptual skills. Future interventions should address selective

attention, alertness, oral-motor strength, and visual perceptual skills.

RUBY: A CASE STUDY OF A SIX-YEAR-OLD GIRL 14

Post-discharge? What specific recommendations would you make for this client/family?

The post-discharge environments will be the school and home settings. The intervention

activities administered in the outpatient clinic will all transfer to both environments.

Recommendations to the school therapist and teacher are: continue working with Ruby on fine

motor skills, pencil grasp, hand writing and safe and effective eating during lunch time. It is

recommended that Ruby be seated in the front row in the classroom, closer to the blackboard.

The recommendations for the family are: to utilize those activities focusing on increasing

attentiveness and cognitive skills such as board games, puzzles, blocks and Theraputty. It is

recommended that Ruby do a gross motor activity before meals. Parents should ensure that Ruby

is seated upright in the chair during mealtime and foods with various textures should be

gradually incorporated into her diet and meals should be related back to skills learned in

Foodland game. Art and music therapy will help Ruby to stay on task with activities. During

story time, picture books or audio books will be helpful. Parents can ask Ruby to retell the story

after it has been read to her, to help her pay attention to it. (Hall, Kaduson, & Schaefer, 2002).

It is recommended that Ruby see a developmental optometrist. The two in Las Vegas are Dr.

Mary Grant and Dr. Mary Carrol. Playing activity books with Ruby will help with her visual

perceptual skills, such as playing Where’s Waldo, connect the dots and matching games. These

activities can be done while seated on a textured “disc sit” cushion, kneeling, laying prone on the

floor or sitting indian style. (Case-Smith) Mighty Bright ruler magnifiers (Amazon.com) can be

purchased to help with reading.

Assessing the needs of children’s learning styles is important for overall classroom

success and can be assessed by a learning styles questionairre created by Learn4Life Publishing

Ltd which is also age appropriate for Ruby (U.K. Department of Education). Accounting for

RUBY: A CASE STUDY OF A SIX-YEAR-OLD GIRL 15

learning styles may help students pay attention because the material will be more appropriately

stimulating to their sensory needs. This can be used by future educators since ruby is entering

into formal education. This assessment determines if children have the prerequisite skills to cope

with the first year of formal education, Key Stage 1. The research study shows the variety of

skills children enter with and give out a questionnaire to help students meet their educational

needs.

Include one page of justification for the therapeutic intervention based on 3 peer reviewed

journal articles.

The primary reason we will be using Theraputty will be to increase strength in the

muscles of Ruby’s hands. Studies by Sanghavi and Kelkar have shown there is a correlation

between the ability to form letters with Theraputty and handwriting skills therefore we

incorporated this into Ruby’s intervention. The population used in the study was significantly

older and would have less potential for learning new tasks since neural plasticity decreases

significantly after the age of seven (Lau). However, Sanghavi and Kelkar (2005) indicate

improved scores of Visual Motor Integration, especially with clay modeling and other visual

motor function activities under supervision of an OT. This will help her with visual

discrimination, a skill that has shown to be delayed especially according to the sensory profile

questionnaire.

Ruby has many issues that interfere with her ability to ignore distractions. This inability to ignore

distractions is severely impacting her occupational performance. Thus, it is important to

explicitly teach Ruby how to ignore distractions in a concrete and easily understood manner. We

decide to do this using the Skillstreaming program Skill 10 "Ignoring distractions"(McGinnis &

Goldstein,1997). There is a substantial amount of anecdotal and evidence based support for the

RUBY: A CASE STUDY OF A SIX-YEAR-OLD GIRL 16

efficacy of Skillstreaming with many populations. Skillstreaming is commonly used to explicitly

teach prosocial skills, such as ignoring distractions, to children with autism, Asperger’s, ADHD,

ED, etc. This program provides multi-sensory ways for a child to learn and practice skills in a

step by step manner. Furthermore, children benefit from the steps of modeling and then role-

playing the skill before practicing using the skill during real occupations. Amendola and Oliver

(2010) stated “A large body of research shows that the three major areas [in Agression

Replacment Training] of Skillstreaming, Anger Control Training, and Moral Reasoning address

key dimensions in helping young people acquire prosocial behavior, thinking, and values. These

approaches have withstood the test of time” (p. 50). For example, The California Institute for

Mental Health provided Aggression Replacement Training via highly skilled professionals to

3,482 children in a variety of settings and found that children showed increases in social skills of

11-40% as rated by the child, their parents, and their teachers (Amendola & Oliver, 2010, P. 49).

Amendolo and Oliver (2010) also found that the Skillstreaming program improved the child’s

grade point averages.

Ruby seems to have significant developmental delays in various visual components. To improve

these skills, we have created an obstacle course that incorporates these elements. Parush and

Hahn-Markowitz (1997) support this view in that “the environment can be used to elicit an

adaptive response.” This study, looking at five to six year old children, used a variety of

assessments looking at visual discrimination, postural, praxis, and body concept demonstrated

knowledge. Subjects in the group, using an obstacle course, improved as a result of the

intervention in the areas of balance, postural and constructional praxis, visual perception, visual

motor integration, body image, following spatial directions, and finger dexterity.

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RUBY: A CASE STUDY OF A SIX-YEAR-OLD GIRL 18

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