Running head: FINAL PAPER
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Final Paper: Intervention Planning
Rachel Csatari and Alyssa Kolanowski
Saginaw Valley State
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Abstract
The following paper outlines the intervention planning process for a case study based on
a young girl, Shelly. To begin, Shelly’s possible diagnoses, ADHD, dyspraxia, and hypotonia
are discussed and an analysis of Shelly’s areas of occupation, performance skills, performance
patterns and client factors is included. Next, potential frames of references/theories are provided
with an explanation of how they relate to Shelly’s strengths and weaknesses. Subsequently,
applicable assessments are included with details of how they are appropriate to administer to
Shelly. After, description of the evidence-based search will be provided; the purpose of the
search was to locate information supporting the best treatment plan including techniques and
approaches. The clinical reasoning process will also be incorporated, in order to give details
concerning the considerations in the decision making of the intervention plan, especially in
regards to the dynamic systems theory and the PEO model. Lastly, future plans for Shelly are
given in the form of three long-term goals, followed by an explanation of the approaches and
techniques that will be used to facilitate Shelly’s achievement of those goals.
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Diagnosis and relevant issues and concerns
The case study describes the difficulties and strengths of a young girl named Shelly. She
has recently been evaluated by a multidisciplinary team at Northwestern University Learning
Clinic, with the findings indicating a possible diagnosis of ADHD, Hypotonia and Dyspraxia.
Attention Deficit Hyperactivity Disorder (ADHD)
The diagnosis of ADHD is common in children; attention-deficit/hyperactivity disorder
(ADHD) is behavioral disorder believed to affect up to 1 in 20 children in the USA (cite).
ADHD is three times more prevalent in boys than in girls, affecting roughly 3% to 5% of
children who attend school (Case-Smith, 2005). Children with ADHD exhibit “inattention,
hyperactivity, and impulsivity that cause impairment in ADLs prior to 7 years of age” (CaseSmith, 2005, p. 194). Inattention is displayed by difficulty sustaining attention during play and
other activities, failure to pay attention to details, trouble with organizing, and avoidance of any
tasks that may require extensive attention. Children who are hyperactive often fidget, have a
difficult time sitting still (e.g., in a classroom setting), cannot play quietly, and are constantly
moving around or always on the go. Impulsivity is often showcased by children who constantly
interrupt others while they are talking, cannot wait their turn, and blurt out responses before a
question has even been asked (Case-Smith, 2005).
As evident by the case study, Shelly has trouble with completing homework assignments
in a timely fashion and staying on task with school work. Shelly does like to encounter other
individuals, however, she usually chooses to play with peers that are a few years younger than
her and engage in play that is immature in regards to her age. She also has had difficulty
interpreting social cues, which results in peers misunderstanding and ridiculing her. ADHD can
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have a negative impact on both her school performance and her social life because it affects
reading skills, learning, academic achievement, social skills, and academic behavior (CaseSmith, 2005).
Hypotonia
Hypotonia is a term that is used to describe children with reduced muscle tone, or low
tone. “Hypotonia refers to an impairment that may be associated with many different conditions,
including those of neuromuscular, genetic, central nervous system, connective tissue and/or
metabolic origins” (Martin, Inman, Kirschner, Deming, Gumbel, and Voelker, 2005, p. 275). A
child with hypotonia exhibits several characteristics including “decreased strength, decreased
activity tolerance, delayed motor skill development, rounded shoulder posture with a tendency to
lean onto supports, hypermobile joints, increased flexibility, and poor attention and motivation”
(Martin et al., 2005, p. 279).
Dyspraxia
Developmental Coordination Disorder (DCD), also known as Dyspraxia, “has been
defined as the breakdown of praxis (action) and the inability to utilize voluntary motor abilities
effectively in all aspects of life from play to structured skills tasks” (Gibbs, J. Appleton, R.
Appleton). Children with DCD have motor problems with dressing (e.g., putting socks on,
fastening fasteners, zipping zippers, putting shoes on, tying shoelaces, using utensils,
showering/bathing, and washing hair), at school (e.g., manipulating scissors, have slow and/or
messy handwriting, immature pencil grasp, and has poor performance in gym class) and while
playing (e.g., have an awkward running gait, balancing, riding bicycle, skating/rollerblading,
skipping, and playing sports) (Polatajko and Cantin, 2006).
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Shelly has a difficult time manipulating or operating objects, prefers eating without
silverware, appears awkward with movement compared to her peers, still requires minimal help
with putting on socks, buttoning small buttons, tying bows and knots, and combing her hair.
These actions that Shelly portrays are evident with children who have Dyspraxia.
Scope of practice
Areas of Occupation
Activities of daily living (ADLs). Shelly still struggles in some basic ADLs including
feeding, dressing, personal hygiene and grooming. Shelly requires minimal help putting on
socks, buttoning small buttons, tying bows and knots and combing her hair. Additionally, she
prefers eating without silverware.
Education. Shelly has demonstrated overall mental and academic skills that in the high
average and above average range, however, she has difficulties staying on task and completing
her homework in a timely manner.
Play. Shelly enjoys playing with dolls and toys and her mother reported that that her
strengths include creative ideas and imaginary play. However, Shelly has difficulty engaging in
age appropriate play.
Social participation. Shelly seeks the company of others, but she usually chooses to
play with peers that are a few years younger than her. In Shelly’s case it would be important to
investigate how her patterns of behavior also influence her engagement in activities throughout
the community and interactions with her family.
Performance Skills
Motor and praxis skills. Shelly displays difficulties with planning skilled purposeful
movements. She appears awkward compared to her peers and she typically has trouble finding
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the proper way to manipulate or operate objects. Therefore, difficulties in motor and praxis
skills appear to be affecting her fine motor skills, especially her ability to efficiently button small
buttons, tie bows and knots, comb her hair and use silverware as well as gross motor skills.
Emotional regulation skills. Shelly displays immature emotional regulation skills. She
seems to have trouble “growing up”. She is sensitive to criticism, can be stubborn and
uncooperative, and also displays temper tantrums, poor frustration tolerance and crying periods.
Additionally, she may appear anxious, and expresses feeling like a failure.
Cognitive skills. Shelly is very intelligent, displaying above average academic skills but
she exhibits difficulty in keeping her personal belongings organized, including her desk and
locker at school, as well as things at home. She also has difficulty staying on task when
completing duties such as homework assignments.
Communication and social skills. Shelly has troubles interpreting social cues, which
results in peers misunderstanding and ridiculing her. This could significantly affect her ability
to make and sustain friendships. In addition, Shelly usually chooses to play with children who
are a few years younger than her. This illustrates her immature social skills, because she feels
more comfortable with children who are younger than her.
Performance Patterns
Habits. Routines are important to evaluate to determine if Shelly has developed habits,
which are useful and support her performance in areas of occupation or are ineffective and
interfere with daily performance.
Routines. No specific routines were outline in the case study pertaining to Shelly’s
patterns of behavior. However, she attends school and she spends most of her free time reading,
playing with dolls and toys, horseback riding and swimming; consequently, her routines most
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likely are shaped around these activities. In addition, transitions between activities (e.g., leaving
home to go to school) are difficult for her and new situations tend to be overwhelming.
Therefore, a comprehensive knowledge of normal routines would be important in order to
develop an intervention plan that focuses on achieving routines to give Shelly some stability
throughout her day in order to reduce her anxiety.
Roles. Shelly’s most significant roles addressed in the case studying include being a
daughter, student, and friend. She is currently struggling to fully engage in these roles at the
level of a typical 8 year old. For example, she seeks friends but chooses children who are a
couple years younger than herself.
Client Factors
Values, beliefs, and spirituality. Values, beliefs and spirituality convey a great deal
about the client’s sense of self, inner attitudes and opinions. In Shelly’s case these would be
important to determine because she sometimes appears anxious and expresses feeling like a
failure. It would be important to determine why she has developed such a low self-esteem and
what occupations are motivating for Shelly in order to plan an effective intervention.
Mental functions. Shelly displays deficits in specific mental functions including
attention and emotional functions. For example, Shelly has difficulty sustaining attention while
completing homework assignments and she has difficulty coping when she is criticized. Shelly
can also be stubborn and uncooperative, often displaying temper tantrums, poor frustration
tolerance and frequent crying episodes.
Neuromusculoskeletal and movement related-related functions. Shelly has been previously
evaluated with findings indicating a possible diagnosis of hyptonia (low musle tone). It would
important to also assess her muscle power and endurance. Additionally, Shelly has a possible
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diagnosis of dyspraxia and she displays difficulty with coordination. She appears awkward
compared to her peers and her parents have noted that she seems accident-prone. Fine motor
coordination is also a concern. Manipulating or operating objects can be difficult for her and
Shelly will often try to apply one solution again and again, even if unsuccessful.
Potential frames of reference and theories
Three frames of reference (FOR) were chosen in order to guide and direct the course of
Shelly’s occupational therapy treatment with the purpose of addressing her deficits in the best
way possible. Each FOR addresses different problems but they all overlap to some extent.
Therefore, a combination of these FOR’s would be most beneficial as guiding theory when
developing Shelly’s intervention plan.
A Frame of Reference to Enhance Childhood Occupations: SCOPE-IT
This frame of reference utilizes occupation as both a means and ends to achieve desired
outcomes of adaptive occupation behavior. Adaptive occupational behavior refers to the
individual’s ability to organize behavior in time with personally and culturally meaningful
activities in areas such as work, rest, play and self-care (Kramer & Hinojosa, 2010). Focus is
placed on improving performance, adapting environments, providing assistive technology as
necessary and education for the child and family while utilizing participation in occupations.
This FOR takes a holistic view in order to promote adaptive occupational performance through
the maximization of the child – environment – occupation fit (Kramer & Hinojosa, 2010).
Therefore, this FOR is applicable for Shelly because of its holistic view. It is very
comprehensive and addresses many areas that she is struggling including work and productivity,
play and leisure, and ADLs. Intervention for Shelly in these three areas would b focused on
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improving performance in these areas by fostering autonomy and mastery, while developing
competence.
Work and productivity for a child is focused on work skills, homework, and chores rather
than a paid activity. Some techniques from this FOR that could be used to improve Shelly’s
performance in work skills include, “scaffolding techniques through the use of (1) cues, (2)
feedback, (3) anticipation of needs and problems, and (4) providing graded assistance” (Kramer
& Hinojosa, 2010, p. 291).
Play and leisure are important occupations for children because they contribute to
shaping a child’s identity and sense of self. “Play is a primary means by which children develop
competence and learn roles of player and friend” (Kramer & Hinojosa, 2010, p. 292). Shelly
tends to engage in play that is immature for her age with children who are a few years younger
than her. Some approaches to help her establish more mature play patterns would include group
play while establishing a “just right challenge” (Kramer & Hinojosa, 2010).
ADLs are important for children to master so that they an achieve independence.
Typically, children begin by developing skills of self-feeding, dressing, toileting and simple
grooming skills during the infant-toddler years and as they reach school age children begin to
master basic ADLs, socialization, grooming, functional mobility and IADLs. Shelly’s main
difficulties include feeding, dressing, personal hygiene and grooming, which are early in the
sequence of ADLs, consequently it is important to provide interventions right away so she can
advance to learning more age appropriate occupations such as socialization, grooming,
functional mobility and IADLs. Therefore some “Occupation-based ADL teaching strategies
may include the use of (1) prompts and feedback, (2) instrumental cues, (3) grading of the
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activity, and (4) repeated opportunities for practice within the daily or weekly routine” (Kramer
& Hinojosa, 2010, p. 296).
A Frame of Reference for Motor Skill Acquisition
The motor skill acquisition FOR focuses on enhancing the child’s ability to solve motor
movement problems to accomplish everyday tasks, participate in self-care, school, play mobility
and social interaction. The main goal of the therapist is to structure an environment that will best
help the children to master new motor skills. Practice and repetition of functional tasks are used
to help organize the child’s behavior (Kramer & Hinojosa, 2010, p. 404). The therapist and child
work together to improve the child’s motor skills with the child being viewed as an active
learner, responsible for his or her own learning (Kramer & Hinojosa, 2010, p. 422). The
therapist is responsible for providing feedback to the child. Generally feedback should be used
the most while the child is learning a new activity. As the child increases in proficiency in the
task the external feedback given by the therapist should be reduced and the use of internal
feedback should be facilitated so that the child learns to reason through motor movement
problems independently (Kramer & Hinojosa, 2010). The expected outcome of treatment using
this FOR is improved motor skills, coordination and balance, as well as increased self-esteem,
social play and motivation to engage in tasks with peers.
Shelly’s difficulties in performing motor tasks can treated effectively through the
strategies utilized in the motor skill acquisition FOR. For Shelly some beneficial approaches
include repetition of tasks and improved use of intrinsic feedback in order to self-evaluate her
movement performance. These strategies will teach her to attempt new motor patterns rather
then applying the same solution again and again, even if she is unsuccessful.
A Frame of Reference to Enhance Social Participation
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Skills for social participation are critical for children’s development and success in school
as well as contributing to growth and maturation into a competent adult. Social participation can
be defined as, “Organized patterns of behavior that are characteristic and expected of an
individual or a given position within a social system” (The American Journal of Occupational
Therapy (AOTA), 2008, p. 633). The goal of this FOR is to help the child develop socially
appropriate habits and routines, increase social participation with peers, and increase positive
interactions between the child and his or her caregivers (e.g., family members, teachers).
The social participation FOR uses many unique strategies to achieve improved social
participation. Occupational therapists provide education to caregivers, teaching them ways to
modify the structure of their child’s physical environment and daily routines to support children
and help them optimally manage their temperamental capacities (Kramer & Hinojosa, 2010). In
addition, specific regulatory strategies can be taught directly to a child in order to help him or her
learn to modulate his or her own emotions and behaviors in challenging events. Furthermore,
role modeling, and occupation-based groups are used to promote children’s participation in
various social settings including schools, after school programs, community centers, mental
health facilities, children’s hospitals or private practices (Kramer & Hinojosa, 2010, p. 335).
Shelly is experiencing difficulty in social participation as evident by her difficulty
interpreting social cues and decision to play with peers that are younger then herself. Therefore,
this FOR is applicable to facilitate more mature social skills and interactions with her family,
peers and teachers. Furthermore the source behind Shelly’s participation problems appears to be
resulting because Shelly often has difficulty managing her temperamental capacities as evident
by her sensitivity to criticism, frequent stubbornness, uncooperativeness, temper tantrums, and
poor frustration tolerance. Therefore, it would be important to focus on teaching her specific
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regulatory strategies to modulate her emotions and behaviors and facilitating more age
appropriate interactions with her family, teachers and friends.
Assessments
The use of assessments in occupational therapy is valuable to determine a baseline for the
child’s performance and to monitor progress. There are many assessments that would be
valuable to assess Shelly’s level of performance and functioning; therefore, in the following
section assessments will be organized according to the domain with which they best assess.
However, it is important to note that there is a great deal of overlap between the areas that these
assessments evaluate.
Areas of Occupation
Strengths and Limitations Inventory School Version (SLI): SLI is a multidimensional
rating scale, which documents the strengths and limitations that may be present in an academic
setting. Items included address memory, reasoning, executive functions, social/emotional status,
communication, reading, writing and mathematics. This would be applicable to Shelly because
as an 8 year 11 month old girl, school is one of her primary occupations. Assessing Shelly’s
strengths and limitations within the academic situation would be extremely helpful in treatment
planning.
Assessment of motor and process skills (AMPS). AMPS is an observation-based rating
scale, which is very useful in measuring the quality of performance in ADLs and IADLs (Asher,
2007). This assessment would be beneficial to Shelly because she is having difficulty
performing ADLs including feeding, dressing, personal hygiene and grooming. Additionally,
there is research supporting the use of AMPS with children who have symptoms consistent with
ADHD because this assessment provides object detailed information regarding how
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characteristics of ADHD affect a child’s functional capabilities. It also, is useful in documenting
changes in performance over time (Prudhomme White & Mulligan, 2005).
Play history: This tool is designed for diagnostic and treatment purposes for children
who display deficits in play (Asher, 2007). Because Shelly is young girl, play is an important
occupation that contributes greatly to development. Shelly is displaying immaturity in her play
patterns so it is important to assess these difficulties and treat them in therapy.
Performance Skills
Bruininks – oseretsky test of motor proficiency, 2nd edition (BOT-2). The BOT-2
assesses comprehensive motor proficiency as well as providing separate measures of gross and
fine motor skills (Asher, 2007). There is research supporting the use of the BOT-2 being a
useful assessment for children with dyspraxia to assess the quality of their gross and fine motor
skills (Cairney, Hay, Veldhuizen, Missiuna, & Faught, 2009). Therefore, this assessment would
be useful for Shelly assess both her gross motor functions and also fine motor difficulties. In
addition, there is a section that focuses on strength and endurance, which would be useful in
determining how Shelly’s low tone affects these areas.
Vineland adaptive behavior scales. The Vineland adaptive behavior scales measure
skills in communication, daily living skills, socialization and motor skills. This assessment uses
a semi-structured interview or a questionnaire format focused on treatment planning (Deusen, &
Brunt, 1997). Therefore, this assessment would be useful in determining a baseline of Shelly’s
current functioning in these four areas in order to plan her interventions.
Performance Patterns
Preferences for activities of children (PAC). This assessment is useful to identify the
child’s preferred activities and prioritize useful activities to include in interventions. The scores
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are used to identify a child’s preferences among recreational, physical, social, skill-based, and
self-improvement activities (Asher, 2007). The PAC would be helpful to establish Shelly’s
current preferences for activities and determine what activities would be useful to include in
intervention planning.
Child occupational self assessment (COSA). COSA is designed to collect data on an
individuals’ self-perception of occupational competence, the importance of occupational
functioning and environmental adaptation (Asher, 2007). This would be a useful assessment for
Shelly because it would help determine how she views her current performance patterns in
occupations, which would be valuable information when determining goals during intervention
planning.
Client Factors
Culture-free self-esteem inventories (CFSEI-3). This assessment is utilized to evaluate
level of self-esteem to determine if an individual may be in need of psychological assistance
(Asher, 2007). This assessment would be helpful in identifying Shelly’s sense of self and selfesteem. It could provide information on the areas contributing to her feelings of failure.
Children’s depression rating scale-revised (CDRS-R). The CDRS-R is used identify
potential depression in children and monitor response to treatment (Asher, 2007). This
assessment would be useful to determine if Shelly’s low self-esteem and frustrations are actually
resulting from depression. If this is true, it could warrant a referral to a doctor for medication. In
addition, the information gained could be useful in intervention planning.
Evidence-based search
Evidence-based practice involves the integration of “best research with clinical expertise
and patient values” (Pendleton and Schultz-Krohn, 2005, p. 55). Before beginning an evidence-
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based search, it was apparent that both Shelly and her family’s values had to be taken into
account. As evident by Shelly’s case study, she has a possible diagnosis of ADHD, Hypotonia,
and Dyspraxia with overall mental and academic skills that are in the high average and above
average range. Shelly’s parent’s want her to improve her ability to communicate and express
ideas in a firm and appropriate manner. They also want her to be able to read and respond to
social cues, learn to plan her actions and “think before doing,” learn how to monitor and release
frustration appropriately, and accept the necessity to do things that are her own responsibility
even though they may not be “fun.”
After finding out what the patient and her family valued, it was time to begin the
evidence-based search. The first website we began searching was Google Scholar. We typed in
key words such as “ADHD,” “Dyspraxia,” “Hypotonia,” “Children,” “Elementary,” “Low tone,”
“Occupational therapy,” “Evidence-Based Practice,” “Assessments” and “Interventions.” We
selected a couple articles from Google Scholar that pertained to Hypotonia because they
contained the most useful information and we felt that they best described Shelly’s condition of
Hypotonia. Subsequent to searching Google Scholar, we searched the databases through
Saginaw Valley State University’s library online. We searched the Occupational Therapy
databases: American Medical Association (AMA Journals), CINAHL, Medline (FirstSearch),
and ProQuest using the same keywords as we did for Google Scholar. When searching the
SVSU databases, we made sure the journals were in English, were evidence-based practice, and
were PDF full text. Through the SVSU library databases, we were able to locate a couple
articles discussing Dyspraxia and ADHD that we felt were appropriate and gave us the most
valid information regarding Shelly and her possible conditions.
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Once we gathered, in our opinion, best research that provided us with more information
concerning Shelly’s condition, we then needed to find evidence that would be useful to develop a
client-centered intervention plan. We found most of the intervention planning information in the
Occupational Therapy for Children book by Case-Smith, Frames of Reference for Pediatric
Occupational Therapy by Kramer and Hinojosa, the Occupational Therapy Practice
Framework: Domain and Process, and several peer reviewed journal articles. Additionally, we
used our clinical expertise and the patient and family’s values to come up with activities that
would help Shelly succeed at home, at school, and in social situations.
Throughout our search of the literature we found many different techniques and
treatments for children with Shelly’s diagnoses and resulting difficulties. Because of the
multitude of problems and domains of functioning affected by Shelly’s conditions, we
determined that a multifaceted intervention plan would be most effective.
According to Case-Smith (2005) successful strategies provided by Occupational
Therapists for children with ADHD include environmental adaptations, social adaptations, social
skills training, self-management techniques and interventions to enhance sensory modulation.
Likewise, according to Chu and Reynolds (2007), an effective treatment for ADHD is behavioral
management; this includes the way that parents react enforce desirable and undesirable behavior.
“For example, they need immediate, frequent and powerful consequences to establish and
maintain desirable behavior (Chu and Reynolds, 2007, p. 379).
For Shelly’s incoordination and motor problems we found that research strongly
supported a task-oriented approach, which is focused on task performance being a result of the
interaction between the person, task, and environment, with the assumption that learning will
lead to changes in motor performance (Polatajko, & Cantin, 2006). Additionally, Pless and
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Carlsson (2000) recommend the specific skills approach as being more effective than the general
abilities approach or the sensory integration approach for use with children who have
developmental coordination disorder. The specific skills approach mainly emphasizes the use of
combinations of correctly performed practice of function skills, appropriate repetition, and
sufficient guidance and time to facilitate skill retention and generalization.
In addition, the care-giving environment plays a very significant role in children’s
successful development. We found a great deal of support emphasizing the importance of OT
intervention utilizing a family-centered approach. “This approach recognizes that each family is
unique; that the family is the constant in the child’s life; and the parents are the experts on the
child’s abilities and needs” (Chu & Reynolds, 2007, p. 377). For that reason, collaboration with
the family is of utmost importance throughout the therapy process in order to empower and
enable the parents to support and encourage their children.
Clinical reasoning process
Clinical reasoning is used to “assess, plan, and provide intervention for children. This
reasoning process enables occupational therapists to think broadly and deeply about their clients
and to develop interventions that are holistic and effective” (Case-Smith, 2005, p. 2). Since
Shelly has a possible diagnosis of ADHD, Hypotonia, and Dyspraxia, we are taking all this
information into consideration when developing and implementing the most client-centered
intervention for her.
The process of completing this paper has been a valuable learning experience. When
determining the applicable frames of reference to guide Shelly’s treatment we decided upon a
frame of reference to enhance childhood occupations: SCOPE-IT to focus on Shelly’s difficulties
in completing ADLs and responsibilities; a frame of reference for motor skill acquisition to work
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on coordination problems; and a frame of reference to enhance social participation to concentrate
on behavior modulation, interpretation of social cues and communication skills. We found
research supporting the use of these frames of reference and specific techniques and treatment
interventions, which corresponded with the overarching theory that we chose. However, as we
engaged in research on common treatments for Shelly’s deficits we became aware of the
multitude of theories and treatment strategies available to treat these conditions and symptoms.
One important treatment approach involves the frame of reference for sensory integration. CaseSmith (2010) notes that this is a common method of treatment for children with ADHD and
Dyspraxia. “The ultimate goal of sensory integrative intervention is to facilitate a child’s
development, self-actualization and occupational performance (Chue & Reynolds, 2007, p. 378).
Therefore, in the future when treating a child with diagnoses such as Shelly we will consider
assessing sensory processing and the use of the frame of reference for sensory integration in the
intervention process.
The process of selecting appropriate assessments for Shelly was certainly challenging.
The PEO model focuses “equally on facilitating change in the person, occupation, and/or
environment.” It suggests, “occupational performance is the result of the dynamic, transactive
relationship involving person, environment, and occupation” (Case-Smith, 2005, p. 66).
Therefore, we wanted to make sure that we took into consideration Shelly, her occupations, and
the environment in which she performs. We gained a comprehensive view of Shelly’s
functioning throughout daily life by evaluating Shelly’s performance in her primary and valued
occupations in the principle environment that they take place. For example, we chose the
strengths and limitations inventory: school version in order to assess Shelly’s strengths and
limitations within the school environment because as an elementary student she spends a great
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deal of time there. In choosing assessments it was important for us to obtain specific information
relative to more specific client factors as well, for example, the BOT-2 was used to gain
information relative to gross and fine motor functioning. Overall, we wanted to gain a holistic
view of Shelly’s functioning that would allow us to more effectively determine goals to plan a
successful treatment plan.
Additionally, we took into consideration dynamic systems theory, because of the strong
interaction of the child’s inherent and emerging skills, the characteristics of the desired task or
activity, and the environment in which the activity is performed (Case-Smith, 2010). For
example, because Shelly has difficulty accepting the necessity to do things that are her own
responsibility we focused on an intervention that was very specific; we kept in mind her current
skills and graded the task so that as she gained skills the task’s difficulty would increase
appropriately.
There were many different areas in which we could have chosen to direct Shelly’s
intervention plan. We had to prioritize and chose goals based on Shelly’s parents current goals
for her. This process was also difficult, because although we chose several assessments to
administer to Shelly we did not have these results to guide our treatment planning. Because of
Shelly’s comorbid conditions we used a comprehensive approach utilizing several of the
techniques we found throughout our evidence-based search.
Intervention planning
Long-Term Goal One
Goal one: Shelly will consistently complete one daily chore on her own in order to gain a
sense of responsibility within 1 month. For this goal, a frame of reference to enhance childhood
occupations: SCOPE-IT was utilized. The intervention that will be used to assist Shelly in
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completing daily chores on her own will be consultation. Collaboration with Shelly and her
parents will be used in order to create a daily chore schedule that Shelly will utilize in her home.
Shelly’s chore schedule will be graded as the month progresses. For the first half of the month,
Shelly will engage in simpler chores such as picking up her toys, making her bed, and setting the
table. For the second half of the month, Shelly’s chore schedule will involve more complex
chores such as dusting, taking out the trash, and emptying the dishwasher.
Education will be provided to Shelly’s parents on correct techniques for facilitating
Shelly’s success in completing daily chores in order to gain a sense of responsibility and
productivity. Scaffolding techniques can be used including the use of cueing, feedback and
positive reinforcement (Kramer & Hinojosa, 2010). This support and instruction given by her
parents will be helpful for Shelly to master these new chores successfully. Providing positive
reinforcement will provide incentive and improve motivation for completing chores. For
example, Shelly must first complete her chore before engaging in play or leisure for the day.
Long-Term Goal Two
Goal two: Shelly will consistently use silverware to feed herself independently within 3
weeks. This goal will utilize the motor skills acquisition frame of reference with a specific skills
approach. Intervention will include therapeutic use of occupations and activities – purposeful
activities and occupational-based interventions. In addition, consultation process will assist the
family in providing appropriate reinforcement especially at home.
Since Shelly has difficulty manipulating objects, having Shelly practice manipulating
various types of objects to prepare her for being able to successfully manipulate silverware for
self-feeding. Occupation-based intervention will include Shelly actually using silverware for
feeding. Proper use of silverware will be encouraged by presenting Shelly with various foods
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that call for the use of silverware (e.g., applesauce, pudding, and yogurt). By structuring the
environment and providing feedback Shelly will learn to properly manipulate silverware. The
intervention will be graded by the amount and type of feedback used. At the beginning of the
intervention, feedback will be provided to Shelly by others (extrinsic) with the use of gestures,
facial expressions, and verbal cueing. As Shelly increases in her proficiency of using silverware,
more focus will be placed on the use of intrinsic feedback so that Shelly is less dependent on
others and is able to plan adaptive strategies through evaluation of her own performance (Kramer
& Hinojosa, 2010).
Long-Term Goal Three
Goal three: Shelly will demonstrate an increased ability to modulate her emotions as
evident by a decreased number of temper tantrums within 4 weeks. For this goal, a frame of
reference to enhance social participation will be used. Intervention will include the use of
strategies and techniques to manage emotions and behavioral challenges in events and social
situations so that Shelly can engage more successfully in activities with peers and her family.
Intervention will first utilize consultation process and individual therapy sessions. During the
consultation process and individual therapy sessions, the therapist will help the parents’ to
enhance their everyday functioning with their child, while providing positive reinforcement and
setting reasonable, but consistent boundaries.
Three examples of techniques that will be used to help Shelly modulate her emotions are
“Count to ten and try it again.” Since Shelly can be stubborn and throws temper tantrums when
she does not get her way, employing this technique will help her to calm down and redirect her
behavior. The next technique would involve providing positive reinforcement to lessen the
amount of temper tantrums and disruptive behavior Shelly demonstrates. Allowing Shelly to
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engage in ten extra minutes of play time or an activity that she enjoys will reinforce good
behavior. When Shelly misbehaves, she will be unable to participate in any play or leisure
activity. Another tactic to help Shelly modulate her emotions and calm down when she is feeling
frustrated or anxious is to simply walk away from the exasperating situation while taking ten
deep breaths.
As Shelly becomes proficient in balancing her emotions she will advance to group
therapy to focus on utilizing these techniques in a more realistic situation. The goal is that by
Shelly improving her behavior and reducing the amount of temper tantrums in which she
engages she will be more capable of engaging in mature social interactions. In addition, as
Shelly learns how to recognize her own emotional feelings and balance them, another later step
will be for her to carry this skill over to recognizing other individual’s emotions and forming
appropriate responses.
In conclusion, through the use of research and clinical reasoning we were able to
formulate an effective intervention plan for Shelly. Several overarching frames of references and
more specific theory, including the PEO model and dynamic systems were especially helpful in
forming a base for our interventions. In the end, we developed three specific long-term goals for
Shelly along with detailed intervention techniques and approaches. All of the goals
corresponded, but targeted different problem areas with the goal of improving Shelly’s overall
functioning in her areas of occupation.
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