Case Study- Jeremy

Nicole Brunne 100613938

Durham College Student
OTA2 3304: OTA Therapeutic Skills 2
Victoria Lo
Tuesday October 10th 2017
Nicole Brunne Case Study-Jeremy OTA2 3304

1) The first component based impairment for Jeremy’s sensorimotor system would be the
under responsivity to sensory proprioceptive and vestibular stimuli. In general, this means
that Jeremy’s sensory system is seeking that extra input from his environment to successfully
play. For Jeremy to sense where his body is in space and how to stay balanced he tends to
play more rough with the kids in his class. He will be constantly moving his body to get that
stimulation and sometimes kicks other kids in circle time. Jeremy also plays rough by
climbing shelves and jumping off tables to give his system the right amount of input so he
knows where his body is. Another school activity that may be hard for Jeremy to participate
in would be recess or gym where sports activities may be involved. Since Jeremy has a hard
time knowing where his body is this might make it more difficult for him to play a sport like
soccer. He may be more rough with the other players and with the ball itself to get that
sensory feedback. (Lo, 2017 September 12)
The second component based impairment Jeremy displays is an over responsivity to
auditory stimuli. This means that certain sounds or pitches are too overwhelming for
Jeremy’s sensory system and he gets overloaded. His system does not require the same
amount of auditory stimuli that another kid would who does not have SPD. For example, in
the classroom when it gets crowded/noisy Jeremy will get overwhelmed and cover his ears
with his hands because of all the noise. He is trying to prevent that extra input from entering
his system. Another activity that may be more difficult for Jeremy would be announcements
on the PA system or even the teachers voice could be overwhelming to his auditory system.
This would make each day at school even more challenging. (Lo, 2017 September 12)
2) A component based impairment in relation to Jeremy’s cognitive integration system
would be his attention capacity or inattention. His attention capacity is much shorter when he
is doing tasks that are not favourable to him or if he has to sit in circle time. With this
inattention, school can be more difficult for Jeremy because he has more energy and moves
on much quicker than other kids may. For example, Jeremy cannot sit still for circle time
with his peers and focus. Instead he is constantly moving his body and disrupting other kids.
Another activity that may be more difficult for Jeremy with a low attention span would be
listening to the teacher when they are giving instructions to line up for recess or for home
time. Usually an activity like this would take at least 10 minutes to get every student in order
and ready to go, so this may cause difficulty for Jeremy to focus and listen for that long. (Lo,
2017 September 12)
3)
Person Factors Environmental Factors Occupational Factors
 disruptive  few friends  independent with
behaviours  has great support toileting routine
 unsafe behaviours from school/family and feeding
 overwhelmed  fully equipped  emerging
 fidgeting school with sensory independence with
 expresses verbally and gross motor dressing
 inattention room  transitioning
 under responsivity  school willing to between tasks is a
to sensory stimuli purchase items he challenge
 over responsivity to needs
auditory stimuli
Nicole Brunne Case Study-Jeremy OTA2 3304

 high energy  EA help all day at  struggles to sit and

school focus during circle
 noisy classroom time
 crowded classroom  follows a visual
 distracting walls schedule
 loves to play with
iPad
 loves Paw Patrol
4) Occupational performance is stated as the ability of a client to perform occupational tasks
in their daily lives (Law et al., 1996). The larger the occupational performance space the
more the patient is more independent. Currently Jeremy’s occupational performance would
not be a “good fit” because there are several factors that are inhibiting his overall
performance. In relation to circle time his occupational performance is not the best it could
be because of many factors. He gets overwhelmed easily with loud noises in the classroom
and busy crowds. In circle time there will be many kids sitting together and this may be loud
for Jeremy as well as feel very crowded in a small space. Since he gets overwhelmed he
resorts to disruptive and self-harming behaviours like kicking or biting himself. This again
would decrease his occupational performance during circle time because he is focused on
coping with his overwhelming senses. He also has an under responsivity to sensory stimuli
which is impacting how he interacts with the other kids during circle time. He resorts to
rough behaviours and even kicks some of the kids. With these behaviours the teacher then
would have to keep stopping circle time and start from the beginning and Jeremy would then
have to sit for even longer. Since he has troubles interacting with kids at school and he lacks
a social circle he may feel threatened or not as comfortable during shared group activities
like circle time. It was stated that some of the kids have started to avoid him because he plays
rough and sitting in circle time with these others kids may be the last thing Jeremy would
want to do.
Since Jeremy also prefers the games he likes, he then has a hard time re focusing and
transitioning into circle time, this would lead him to paying even less attention. This impacts
his overall learning and ability to handle group tasks. He does have an EA that is with him all
day and encourages the use of a visual schedule which helps Jeremy to prepare and know
what is next in the day. This is a great technique to use to re-focus Jeremy on transitioning
into circle time but it might not be a “good fit” yet since Jeremy still fidgets and wiggles
during circle time. Being independent for his basic ADLs allows Jeremy a sense of
accomplishment and he can excuse himself from circle time just like all the others kids.
Finally, the environment of the classroom itself can have an impact on Jeremy’s
occupational performance. If the classroom is small and overcrowded especially during circle
time, this could be overwhelming for Jeremy. Having a distracting and busy looking room
can increase the chance for Jeremy to pay less attention to circle time because they are many
things to look at and activities he may want to play with around the room.
 Nicole Brunne Case Study-Jeremy OTA2 3304

Before intervention: “poor fit”  goal to aim for: “good fit”

Occupational Occupational
Performance Performance

Occupation
Occupation

Person Environment
Person Environment

Person: Occupation: Environment:

 Attention span
 Under responsivity to
proprioceptive/vestibu
lar input
 Over responsivity to
certain noises and
pitches
 Disruptive behaviours
 High energy
 Easily overwhelmed
 Fidgeting
 Chewing on items
 Prefers his games
over circle time
 Does not transition
well to circle time
 Follows a visual
schedule for when
circle time is
 EA assistance to
prepare for circle time
 Disrupts overall
efficiency of circle
time
 Busy classroom
 Overwhelming noises
from PA or teacher
 Kids may be teasing
him, they avoid him
 Distractions on the
wall and shelves of
room
 Uncomfortable area to
sit for circle time
 Bright classroom
lights
 Having to share
 Kids sitting to close
during circle time

5) There are many strategies that could be used to try and improve Jeremy’s attention and
productivity during circle time. Since the school is willing to advocate for him and purchase
any item he may need this will help to open up many options for Jeremy.
The first treatment tool I would provide Jeremy with would be a heavy weighed stuffed
animal (preferably Paw Patrol). This weighed stuffy will provide Jeremy with that extra
sensory stimulation he is looking for and he will spend less time disrupting the circle and be
able to focus on the circle time activity. This extra sensory stimulation provides Jeremy with
added pressure and comfort. It lets him feel where his body is in space and this then controls
how he uses his body. This will help him to sit still longer and fidget less. Depending on
how much the school is willing to purchase for Jeremy, there are devices that essentially
Nicole Brunne Case Study-Jeremy OTA2 3304

give a “hug” to the child to provide them with deep touch pressure. If Jeremy was ever upset
this could be helpful to have in the classroom (Edelson et al., 1999).
Since Jeremy already uses picture communication techniques I would incorporate a
“First Then” picture board. At the beginning of each day Jeremy and his EA can select from
a variety of pictures that indicate certain activities throughout the day. For example, each
morning before a task Jeremy gets to pick what the “then” will be and the EA picks what the
“first” will be. By using a “first then” picture board, we can visually show Jeremy that if we
complete the first task he may not like, we then can move on to a more favourable task he
himself picked out. This technique involves Jeremy which also adds motivation for him to
complete the first task, if he knows when he is done he gets to play with his iPad. (Lo, 2017
September 26)
FIRST Circle Time THEN iPad

The third strategy I would provide to Jeremy’s school would be to take use of the gross
motor room. Before circle time is scheduled to start I would have the EA take Jeremy to this
room to allow him to use up some of his built up energy. As well in this room he can climb
on obstacles and play rough in a controlled environment to get that added proprioceptive
input. By allowing this high energy play time before circle time will increase the attention
span Jeremy will have to sit for at least 3 minutes during circle time.
The final strategy I would provide Jeremy and his EA with would be the “Incredible 5-
point scale”. This scale could be designed with the help of Jeremy and what certain feelings
and emotions he presents with when he is completely focused and when he is starting to get
fidgety. He can help personalize it with Paw Patrol characters and make it his own. By
allowing him to help gets more “buy in” from Jeremy to be more involved with this tool.
This tool is used to help Jeremy self-regulate his emotions and behaviours by recognising
how he is feeling in a certain moment, what it looks like when he feels this way and how he
can resolve the situation. (Lo, 2017 September 26)
Nicole Brunne Case Study-Jeremy OTA2 3304

Feels Like: Looks Like: I can:

5 Kicking Take a break with my EA

Screaming Take 5 deep breaths
Biting myself Hold my Paw Patrol stuffy
I’m really Hitting my friends Try to go back to a 4
upset, I Running away
can’t focus!
4 Covering my ears Go for a walk with EA
Yelling Get a drink of water
Lying on the floor Go to a quiet place
I am starting Move my mat away from others
to get Try to go back to a 3
frustrated.
3 Distracting others Take deep breaths
Using my loud voice Hold my weighted stuffy
Not listening to my teacher Ask for help
I’ve got a Starting to fidget and wiggle Try to get back to a 2
problem.

2 Sitting still on my own mat Have a drink of water if tired

Quiet voice Remind myself IPad is next
Hands to myself Tell myself “I am doing great!”
Trying to listen as best I can I can have a break after
I’m doing ok. Tired eyes

1 Sitting still I feel happy about participating

Listening to my teacher Gold stickers afterward!
Not speaking out loud Have fun!
Calm Keep smiling!
Feeling great! Feeling happy!

6) The first activity I would choose would be a high energy gross motor game. I would take
Jeremy into the gross motor room where there is a slide that also has a ladder to climb up. I
would tell the EA she can give him a total of 3 minutes to complete this activity, even use a
visual timer so that Jeremy can see how much time he has left. He will go as fast as he can
and take a Paw Patrol bean bag from the basket, climb up the ladder, go down the slide, and
then throw the bean bag into a barrel that is a few feet away. I would have him climbing the
Nicole Brunne Case Study-Jeremy OTA2 3304

ladder to provide him with proprioceptive input into his legs and going down the slide is a
fun way to reward climbing the ladder. He can choose to go down the slide on his bum or
even his belly with supervision. At the end of the slide there would be a soft foam block pit
to land in to again provide him with extra sensory input. Finally, throwing the bean bag into a
barrel far away allows him to really work his upper extremities. The EA can be encouraging
him throughout the task to get as many bean bags in the barrel as possible to make it fun.
Overall, this will help to burn off some of his energy reserves and better prepare him for the
next activities to come.
The second activity I would choose would be to do some “hard work” with Jeremy. Hard
work is another term for using an activity that provides Jeremy with active deep pressure (Lo,
2017 September 26). For this activity I would require heavy weight balls that are about 10lbs
each and a variety of colours. I would allow him to pick which colour he preferred to play
with. For this activity we would play a game of pushing the balls back and forth in various
directions. Since the balls are heavy Jeremy will have to go on his hands and knees and push
with both hands. He can push the ball straight forward to me or to the side so I have to lean to
stop the rolling ball. I would then do the same to Jeremy. This activity will get Jeremy
working hard and providing his muscles with that deep pressure input. The EA can set a
visual timer for 3 minutes to complete this game.
The third activity I would choose would be to provide Jeremy with 5 minutes of passive
deep pressure. This would be work done by the therapist/EA or by an item providing the
pressure (Lo, 2017 September 26). I would use a heavy weighed blanket with Paw Patrol
patterns on it and sit Jeremy in the sensory room with the lights dimmed. He would be sitting
in a comfy bean bag chair that also hugs him tight. I would choose this item because it
provides Jeremy with sensory feedback and also can be used to calm him down. Along with
the weighed blanket we would do a breathing exercise. I would play a game of “Simon
Says”. I would go first and take a deep breath in and then exhale saying “eeee” or “oooo”. I
would then have Jeremy copy what I did. Having him copy me with these sounds forces him
to take a deep breath in and out which is very calming and relaxing. Practising breathing
techniques is very important with kids to show them how to use their big voice and to know
how to calm themselves down. It also strengthens their muscles for inspiration and expiration
(Rothman, 1978). If Jeremy does not fully understand how to take a deep breath I would put
his stuffy on his belly to show him how his stuffy goes up with a deep breath in and down
with an exhale.
7) SOAP Note:
S- Jeremy was dropped off at school by his parents. He went to put away his backpack and the
parents gave verbal and written consent for the following 4 sessions. Jeremy’s mom stated that
“Jeremy was feeling a bit tired and groggy today” before she left. ________________________
O- Jeremy was taken to the gross motor room to start the therapy session. The EA came along to
this session to learn and take notes for the future. Jeremy completed 4 tasks throughout this one
session. Jeremy first had 3 minutes to transfer as many Paw Patrol bean bags up a ladder, down a
slide, landing in soft block pit, and finally throwing the bean bag into a barrel starting 3 ft away.
Jeremy completed this for 3 minutes and transferred 10 bean bags. Jeremy ran the obstacle
instead of walking and went down the slide on his belly 5 times and on his bum 5 times. Jeremy
needed visual demonstration before the task. Jeremy then completed 3 minutes of pushing a
weighted ball back and forth to a partner. The ball was 10lbs. Jeremy chose the blue ball to use.
He pushed the ball back and forth 8 times. Jeremy did this task on his hands and knees, using
Nicole Brunne Case Study-Jeremy OTA2 3304

both hands to push the ball. Finally, Jeremy went to the sensory room to complete the last 2
activities. For 5 minutes, Jeremy sat in a bean bag chair with a weighted blanket draped across
him. While sitting, he completed breathing exercises with his partner by playing Simon Says. He
repeated back 2 “o”’s and 2 “e”’s, using deep breaths in and out for a minimum of 2 seconds.
The Paw Patrol stuffy was used to demonstrate how his belly goes up and down for breathing.
After the session Jeremy was returned to his classroom.
A-Jeremy tolerated the therapy activities well. He was tired at first but more enthusiastic when
his favourite character was involved, Paw Patrol. He completed every task that was asked of him.
He needed visual demonstration before each new task. The visual timer kept him on task.
P-Jeremy will continue sensory therapy sessions Mondays and Thursdays with OTA (3 sessions
left) and continue the sensory activities daily with the EA from present onward. OT will be
notified of Jeremy’s progress and treatment session. ___________________________________

Nicole Brunne
OTA/PTA Student
Nicole Brunne Case Study-Jeremy OTA2 3304

References

Edelson, S., Edelson, M., Kerr, D., & Grandin, T. (1999). Behavioral and physiological effects of
deep pressure on children with autism: a pliot study evaluating the efficacy of Grandin’s
Hug Machine. E-Jounral of American Journal of Occupational Therapy. 53(2), 145-152.
Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/10200837.

Law, M., Cooper, B., Strong, S., Stewart, D., Rigby, P. & Letts, L. (1996). The Person-
Environment- Occupation Model: A transactive approach to occupational performance.
E- Journal of Canadian Journal of Occupational Therapy. 63(1), 220-234. Retrieved
from http://journals.sagepub.com/doi/abs/10.1177/000841749606300103.

Lo, V. (2017, September 12). OTA2 3304. Intro to neurological rehab and mental health within
the PEO framework.

Lo, V. (2017, September 26). OTA2 3304. Neurodevelopment conditions in pediatrics (part A).

Rothman, J. (1978). Effects of respiratory exercises on the vital capacity and forced expiratory
volume in children with cerebral palsy. E-Journal of Physical Therapy. 58(4), 421-425.
Retrieved from http://europepmc.org/abstract/med/635021.