Running head: CASE STUDY

Case Study: Gabrielle

Johnny Rider, Kamrie Fryer, Kristen Kincaid, Teavy Moeung, Brett Bonetti, Brandon Roberson
Touro University Nevada

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Activities of Daily Living

Gabrielle can take off her own socks but needs her parents to help with donning and
doffing the rest of her clothes, including her bilateral AFOs. Her parents still assist her with
bathing to make sure she is safe. She needs her special soft towel to dry off with and wont use
other towels because she doesn't like how rough they feel. She is able to doff her cochlear
implant but not don it. She cannot don or doff her hearing aids nor handle them properly. She is
struggling to brush her teeth. She can grasp the toothbrush but has difficulty coordinating the
hand and mouth movements. She can brush her own teeth if her parents squeeze the toothpaste
on her toothbrush and she loves to brush her own hair before bed.
She is not potty trained but tells her parents when she has soiled herself. She needs assistance
with toilet hygiene. She can independently eat finger foods and loves chicken nuggets. She does
not like mushy, grainy foods, such as oatmeal. She can use a gross grasp on forks and spoons, but
prefers to finger feed. She can ambulate around her house but does fall and trip over toys
frequently.
Instrumental Activities of Daily Living
Gabrielle is able to walk alongside her mother when they visit the store and always asks
to hold hands in public places. She can also sit independently in the shopping cart. The family
has a small dog for a pet. Gabrielle loves to help care for the dog by helping to fill the water and
food bowl. Her mother has put the food on the floor of the pantry so Gabrielle can scoop some

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out to feed the dog. She also attends church with her family on occasion and enjoys the children's
program.

Rest and Sleep

She sleeps an average of 9 hours at night with a 1-2 hour nap after preschool. It is
important to note that Gabrielle has to take off her cochlear implant and hearing aid at night and
when napping. This leaves her right ear completely deaf and her left ear profoundly deaf. Noises
do not disturb her sleep but she is very sensitive to vibration and light while sleeping. If the
garage door opens or someone tries to vacuum, Gabrielle will wake up.
Education
She attends a preschool for children with hearing impairments for day, 5 days per
week. She loves going to preschool and has made many friends. She likes her teacher and tells
her parents about preschool every night.
Work
Gabrielles responsibilities at home include picking up her toys and books in her room.
Like other children, she perceives this as work and dislikes it. She frequently needs help finding
toys and books in her room due to visual scanning deficiencies. Her parents have to remind her

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multiple times to pick up toys she has missed. She also attends outpatient therapy each week to
work on ocular and oral motor deficits as well as balance and fine motor skills.
Play
Gabrielle enjoys playing with the other children at preschool. She likes to play with
blocks and puzzles. She tries to keep up with other children but stumbles and falls frequently and
cannot run skillfully yet. She prefers to play on even surfaces and struggles to walk on the
uneven surface of her backyard and playgrounds. Therefore, she avoids playing on the
playground because of her clumsiness and frequent falls. Gabrielle is unable to successfully
scan the environment due to ocular motor deficits. This leads to frequent falls when playing
outside with other children. She plays with most of her toys in a seated position and does not like
to play on her stomach. Gabrielle has an older sister whom she adores. She follows her older
sister around the house and imitates whatever she does. Gabrielle will play alone or with friends
if they visit. When there are others to play with Gabrielle will have dress-up parties and play
together. One of Gabrielles favorite things to do is play with her dollhouse. She engages in
imaginary and pretend play frequently with her dolls and sets up parties for her entire doll
collection.
Leisure
Gabrielle enjoys watching Disney movies and Signing Time. She loves when her
parents take her for a walk in her stroller. She frequently asks her parents to go for walks around
the neighborhood because she likes to see the horses down the street. In her bedroom, she has
glow in the dark stars and a light up mobile. She loves to lie in her bed and look up at them. She

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enjoys when her parents read her books and tries to follow along by looking at the pictures.
However, her parents have noted that Gabrielle has a hard time finding objects on the book pages
when asked to locate them.
Social participation
She attends preschool with other children that also have hearing impairments. At the
school Gabrielle and the other students are developing speech and language skills. The preschool
environment is set up to promote visual access and allow the children to see the teacher
whenever she is speaking. Although Gabrielle is a chatterbox, she has problems with articulation
and those who are not familiar with Gabrielle have trouble understanding her speech. She enjoys
the times her family goes to church and has many friends in the children's program. Her parents
have set up play-dates with a 5 year old girl who also has charge syndrome. However, the family
lives in another city and their daughter does not attend the same preschool. Once a month, the
two families spend Saturday morning together alternating between houses and community
events. While Gabrielle was in early intervention, her family was introduced to an American
Sign Language class. The class is taught monthly, by the school district, and Gabrielle and her
family continue to attend on Monday evenings. Gabrielle actively signs with the other children
with hearing impairments. Gabrielle speaks more than she signs, but she enjoys the friendships
she has made with the children in the class and wants to keep learning ASL. Gabrielle and her
sister like to sign together when they play.
Characteristics of Movement, Postural Reactions, and Reflexes

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Gabrielles movements and physical developmental milestones have been severely

delayed due to her diagnosis with CHARGE syndrome. Her occupational therapist has addressed
specific tasks like safety, feeding, and donning/doffing of important self-care materials. Since
she has slightly low tone in her upper extremities, activities like supported sitting at mealtime,
crawling during play, and prone positions that require arm support, are difficult for her to
perform. The low tone and lack of endurance in her core muscles causes problems with postural
development because she lacks the stamina and strength to support her during play activities
were she needs to reach for objects. This causes compensation in other body movements to
complete the tasks. With low tone stemming from her core and back muscles, certain
developmental tasks such as self-feeding are much more difficult. In addition, her difficulty
performing table top activities in preschool may place Gabrielle behind the learning curve. Her
inner ear dysfunction further impacts her gait. Since Gabrielle also has a vision problem, it
makes it difficult for her to practice grasping skills and reaching for objects to play with. Vision
problems can also inhibit her ability to watch others demonstrate and teach proper physical
movements. All of Gabrielles motor impairments, in addition to lack of postural support and
righting reactions, affect her ability in play as an occupation. As Gabrielle gets older, there may
be more concerns about her ability to sit at a desk and perform more table top activities for long
periods of time in school. It is important for her to be able to carry out fine motor tasks such as
writing and manipulation of school-based supplies. This can be hindered with low tone in her
upper extremities and the ability to maintain a seated posture with the lack of core muscles.
Gabrielle tends to use a lot of gross motor grasps when donning and doffing clothes instead of
performing more fine motor skills, this stems from her low tone as well as trouble with her vision
and focusing on smaller objects. Postural issues pertaining to her gait will continue to be one of

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the most important movements for Gabrielle especially when she does activities on the
playground with various obstacles and surfaces. Additionally, with difficulty with
accommodation, she needs the balance of righting reactions to help keep her in safe and proper
positions will be a concern that her occupational therapist and parents should continue to
address.
Sensory Integration or Self-Regulation Issues
Gabrielle has tactile aversion with squishy and rough textures. In conjunction with her
poor fine motor skills, this may indicate that she has a tactile discrimination and perception
disorder. This will interfere with her ability to develop age appropriate manipulation skills.
Inadequate tactile perception will also interfere with her feedback loop that assists in guiding fine
motor tasks such as writing with a pencil or manipulating a spoon. Furthermore, Gabrielle has
difficulties with accommodation, which is also associated with tactile perception disorders and is
linked with problems with hand-eye coordination. This may prove to be more important as
Gabrielle ages due to the likelihood that her vision will decrease due to her small optic nerves.
Since Gabrielle does have difficulties with tactile perception, she may be relying on
compensatory strategies like using her vision for tasks that should operate on an automatic level.
Besides taking a great deal of energy, these compensation techniques will become obsolete if her
vision deteriorates. In addition, postural-ocular deficits, like Gabrielles problems with
accommodation, limit her ability to safely navigate her environment. Another issue is her lower
than average tone, especially in the extensor neck muscles demonstrated by her distress when
placed in prone. This indicates that she lacks the muscle strength and stability to extend her neck
and push herself up easily. In addition, Gabrielle lacks postrotary nystagmus, due to the

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ossification of 2/3 of her semicircular ear canals of each ear. This can cause difficulty with her
vestibular function and her bilateral integration (Case-Smith & OBrien, 2010).
Application of PEOP
The Person-Environment-Occupation-Performance (PEOP) Model is an ecological model
that focuses just as extensively on the environment as it does on the person. This model offers a
client-centered approach, focusing holistically on the person, environment, occupation, and
performance to ensure well-being and quality of life. The person aspect of the PEOP focuses on
the clients skills, interests, and experiences, the environment displays the clients cultural,
social, and physical context, the occupation seeks to find what it is that the client wants or needs
to do and what brings meaning to the clients life, and the performance aspect portrays what
occupations fall within or outside of the clients performance range.
In the case of Gabrielle, to understand her as a person using the PEOP model, her
values, interests, skills and abilities, and life experiences must be acknowledged. Gabrielle was
born 35 weeks gestation and in addition to this prematurity, she has many deficits through her
life experiences. She has been diagnosed with choanal atresia as well as Charge Syndrome. She
has small optic nerves which may become as issue as she ages, profound hearing loss causing her
to undergo a right cochlear implant surgery as well as having to wear a hearing aid on the left
ear. Many of these deficits have affected her skills and abilities. Sensorimotor skills such as
visual motor, grasping skills, and protective reflexes are delayed. She has displayed tactile
aversions with items such as squishy rubber, rough towels, and does not like mushy food such as
oatmeal. Emotional and behavioral deficits include her dislike for lying in prone by crying and
placing her head down on the therapy mat. She also has oral motor issues which most likely
contribute to her aversions to eating food. Due to ocular motor issues, she is unable to scan her

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surroundings, has difficulty with balance, and portrays definite concern for safety. However,
Gabrielle displays age-appropriate cognitive abilities in addition to being able to accomplish
many fine motor tasks such as manipulating writing tools, imitating a variety of scribbles, and
use gross grasp to manipulate objects such as blocks and puzzle pieces. Socially, Gabrielle is
known as a chatterbox who displays age-appropriate interests. Intrinsic factors such as the
physiological, cognitive, spiritual, neurobehavioral, psychological components of the person play
a vital role in Gabrielles quality of life.
In an ecological model such as the PEOP, the environment includes extrinsic factors that
are ever changing along with the person. Associated components include social support, social
and economic systems, culture and values, built environment and technology, and most notably,
the natural environment. Her parents play a major role in social support since they have been
with her every step of the way, witnessing obstacles, challenges, and milestones since she was
born. In addition to Dr. Morris, her physician, Gabrielle is able to receive therapy from an
occupational therapist, physical therapist, and a speech therapist at an outpatient clinic. Having
this array of professionals as a part of her intervention definitely helps with her future prognosis.
One of Gabrielles natural environments is her preschool in which she attends half the day for
five days per week. The other children in her class also have hearing impairments. This can be
beneficial for Gabrielle since the school is designed for children with hearing disabilities thus the
school addresses all the facets that come with being hearing impaired. On the other hand,
Gabrielle does not have the chance to assimilate with other children in her age range that are
typically functioning and can offer her ideal imitation and role-playing for her age range. Thus,
for Gabrielle, her environment may hinder or enhance her occupational performance.

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Gabrielles primary occupation is being a kid who plays and attends preschool and
community events with her family. She takes on the role of a daughter, sister, and pet owner. She
has household chores such as cleaning up after herself and plays a minor role in feeding the dog.
She also is a little sister who loves to play with and imitate her older sister. Outside of school,
she also has friends at church and in a playgroup that her parents set up. In the playgroup she has
another friend with Charge Syndrome that she has built a special bond with. Signing is major
component of her play. Other areas of occupations have been aforementioned in more extent.
The person, environment, and occupation, in combination, play a major role in her
occupational performance. Her developmental delays also impact her occupational performance.
For example, although Gabrielle is a chatterbox she has articulation issues due to her low
tone. Additionally, she falls a lot due to her difficulty to scan the environment along with balance
deficits occurring in many environments, such as at school, church, local parks, and her own
backyard. This makes it difficult to keep up with her friends and sister during playtime. She has
immature grasping skills making it harder to play with dolls, participate in color-time, and play
in the sandbox with her friends. Gabrielle still requires assistance in self-care skills such as
dressing, and using the restroom. Through the use of adaptive equipment such as cochlear
implants and bilateral AFOs, her occupational performance has improved. She can hear, allowing
for more interaction with people as well as better awareness of her surroundings. Also, her
AFOs help her with her gait pattern and functional mobility.
The PEOP model shows that the person, environment, occupation, and performance, are
all closely linked together; in which one can easily affect any aspect of another. For Gabrielle,
the PEOP is a client-centered model that can help her as a 3 year old who is still continuing to
change as a person while she learns to navigate her disability in dynamic environments. The

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model can help Gabrielle work on hindered occupational performance areas that are meaningful
to her (Boyt Schell, Gilen, & Scaffa, 2014).
Theories and Practice Models
The frames of reference that are most useful with Gabrielle are the compensatory and
dynamic systems theory. The compensatory frame of reference allows for adjustments to be
made to the environment, materials, or utilization of a technique to allow the desired occupation
to be accomplished. In the case of Gabrielle, who has diagnosis of CHARGE syndrome, she will
need to use a variety of compensatory techniques to assist her in being as functionally
independent as possible in her daily occupations.
Vestibular deficits and visual scanning difficulties impact Gabrielles ability to safely
navigate her environment. Compensatory strategies, like altering and adapting her home
environment through organizational techniques, will improve her safety and ability to function
within her home. Organizational techniques that can be utilized include having specific areas for
items she uses daily and providing easy access to these items, repositioning furniture along walls,
removing rugs, and eliminating clutter. Currently, she is unable to don and doff her clothes
independently. Gabrielles oral motor difficulties include low tone and endurance that decrease
her ability to pucker and blow. Furthermore, it also affects her lip closure and jaw stability.
During feeding tasks, Gabrielle can use compensatory adaptations by adjusting the type utensils
and kitchenware to promote greater success and independence when self-feeding. By using
compensatory techniques, Gabrielle will be able to effectively engage in her everyday
occupations.
Dynamic systems theory is an ecological approach that focuses on a childs functional
performance, the features of the preferred activity/task and the environment. Development of

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motor skills occurs within different stages which includes cognitive, associative, and
autonomous. There is also collaboration of three processes that include cognition, perception,
and action. These three processes are continuously changing and interacting with each other and
have profound correlations with motor skills and performance. Dysfunction occurs when there is
lack of flexibility or adaptability of movements to accommodate task demands and
environmental constraints which are exemplified by Gabrielle ( Case-Smith & OBrien,2010).
Gabrielle has a variety of systems that are affected by Charge Syndrome including:
vestibular, auditory, and visual. She has had ossification of 2/3rd of the semicircular ear canals of
each ear affecting her vestibular system which increases falls when she walks. She has
undergone right cochlear implant surgery and wears a hearing aid in her left ear. Gabrielle has
difficulty with her visual perception due to ocular motor deficits in convergence, divergence,
accommodation and with her ability to scan her environment efficiently. This has a profound
effect on her ability to navigate her environment safely. She has difficulty walking on uneven
surfaces. Therefore, she is unable to safely engage in some age appropriate outdoor play
activities like playing on the playground.
The functional synergies that Gabrielle has developed due to her vestibular limitations,
may not support the best movement patterns. In addition, low tone and limited oral motor
endurance have impacted Gabrielles ability enunciate her words clearly. Gabrielle lacks strength
and dexterity in her fine motor skills as demonstrated by her difficulty maintaining a pincer
grasp. She also dislikes lying prone, likely due to her weak neck extensor muscle tone. The
dynamic systems theory focuses on learning new movements and skills through transition
periods where critical changes occur in motor behavior that will facilitate desired performance in
oral motor, fine motor, and increasing extensor tone. Thus, since Gabrielle has multi-sensory

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deficits, the compensatory frame of reference and dynamic systems theory serve as a great
foundation for future intervention plans.
Assessments
Children with CHARGE Syndrome very frequently have developmental delays,
indicating that the Developmental Profile 3 (DP-3) would be purposeful in determining
Gabrielles levels in physical, adaptive behavior, social-emotional, cognitive, as well as
communication. The DP-3 is a great resource not only because our client fits in the required age
range for this assessment, birth through 12 years, but also if an interview is not possible, a
parent/caregiver checklist can be completed by Gabrielles caregiver in the comfort of their own
home. The DP-3 has been revised, standardized, and updated, which will provide us with an
accurate and effective way to screen for developmental delays usually in less than an hour (20-40
minutes).
CHARGE Syndrome is the leading cause of congenital deafblindness, but unfortunately
there are no standardized tests which exist for evaluating individuals with combined visual and
hearing loss. Deafblindness is a condition where the individual has little or no useful sight or
useful hearing. Individuals are considered to be deafblind when the mixture of their hearing and
vision loss causes such a severe communication and developmental delay that they require
extensive and unique adaptations. With this said, it is evident that two different tests, one to
assess vision (which is usually lost later), and one to assess hearing, will be needed for
individuals suspected of being deafblind or having a prognosis of progressive sensory loss.
In order to test Gabrielles vision, the Erhardt Developmental Vision Assessment (EDVA) is
appropriate. This is a criterion-referenced assessment. The EDVA will help to evaluate and
possibly lead to the treatment of her eye-hand coordination difficulties. Categories assessed by

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the EDVA include pupillary reactions, eye responses, eyelid reflexes, localization, fixation,
ocular pursuit, and gaze shift. The only downfall to this assessment is there are numerous
deficiencies (non-standardized materials, lighting, unclear administration instructions, etc.).
Another assessment that may be beneficial to Gabrielle is the Beery VMI because it looks
at the integration of visual and motor abilities, which we call eye-hand coordination. This
assessment tool will offer a different developmental perspective of Gabrielles vision because it
is a norm referenced assessment, thus comparing Gabrielle with other children her age, while the
EDVA tells us about specific criteria. The Beery VMI screening can give us a better insight as to
what interventions may be helpful for Gabrielle. Possible interventions may include assistance,
particular services, educational effectiveness, and will help with advancing research. The Beery
VMI is an assessment that all health professionals can use with Gabrielle because it spans ages
from 2 to 99 years.

Problem Statements
1.) Gabrielle is unable to safely engage in play activities outside due to inability to walk on
uneven surfaces secondary to vestibular deficits.
2.) Gabrielle has difficulty finding and picking up her toys due to scanning,
convergence/divergence deficits.
3.) Gabrielle is unable to enunciate her words clearly due to low tone and oral motor issues.
4.) Gabrielle is unable to pay attention to her teacher during story time due to difficulty with
neck extension.

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5.) Gabrielle has difficult donning and doffing her hearing aid due to lack of strength to maintain
pinch.
Family/Caregiver/Child goals
Parents want Gabrielle to (1) put on and take off clothes independently, (2) help with
morning routine by brushing teeth independently, (3) play safely inside/outside, (4) handle
hearing aid/cochlear implants carefully, (5) drink from age appropriate cup, (6) be potty trained.
COAST goals
1. Gabrielle will safely navigate uneven surfaces and scan her environment independently by 6
months.
2. Gabrielle will independently don/doff elastic waist pants in preparation for bathroom use and
dressing routines by 6 months.
3. Gabrielle will properly don/doff hearing aid and cochlear implant and put them in carrying
cases independently by 6 months.
4. Gabrielle will independently drink from an age appropriate open cup with no spilling by 6
months.
Objectives for COAST Goals
1. Short term: Gabrielle will traverse an obstacle course in therapy gym with minimal verbal cues
and no falls 3 out of 4 trials by 2 months.
Long term: Gabrielle will be able to play outside on a playground with her sister safely with
minimal supervision by 4 months.
2. Short term: Gabrielle will make a felt and velcro sandwich using the felt/velcro pieces by
pulling apart the ingredients and assembling them independently by 2 months.

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Long term: Gabrielle will don/doff elastic waist pants from the knee using backward chaining
from the therapist independently by 4 months.
3. Short term: Gabrielle will play with Lite-Brite using age appropriate pincer grasp and in hand
manipulation independently by 2 months.
Long term: Gabrielle will string 20 various sized beads sequentially on string to make jewelry
independently by 4 months.
4. Short term: Gabrielle will blow into a harmonica producing sound with full mouth closure
independently in 2 months.
Long term: Gabrielle will be able to blow through a large diameter straw to make bubbles in
water to make bubble art independently by 4 months.
Activities for Objectives
1. Short term: Sorting toys into categories, brain gym matching cards, Memory game, obstacle
course, and playing catch.
Long term: Freeze tag, find hidden objects in a picture, and find hidden objects in the room
2. Short term: Playdough, tug of war, and Velcro sandwich stacking game.
Long term: Dress a doll, play dress up, and put toys away in elastic strap bag.
3. Short term: Lite-Brite, board games with small pieces, and play with kids rubber stamps.
Long term: Make jewelry with beads in different positions, practice donning/doffing AE, and
lacing activity.
4. Short term: Blow bubbles and make bubble art, blow pinwheel, hold Popsicle stick between
lips, suck on flat lollipop, Y-chew, harmonica, and drink with different size straws.
Long term: Blow cotton ball sheep into barn with straws on scooter, blow boat without straw,
play with different whistles, and blow up balloons.

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Activity Descriptions

-Obstacle course: Therapist will set up a unique obstacle course with objects that Gabrielle will
need to move around, over, under, and through. This will be a multisensory activity requiring
visual scanning, adaptive responses to vestibular and proprioceptive input, accommodation,
walking on uneven surfaces, flexibility, dynamic balance and demonstrate safety. Modeling and
verbal cues may be necessary to improve safety.
-Freeze Tag: Freeze tag can be played with Gabrielle and family members present. Rules can be
adjusted to include different ways of walking (crawling, running, hopping, backwards, etc.) and
different positions to hold when tagged (freeze standing on one foot, tip toes, with hands in air,
on stomach, etc.) to promote gross motor skills, postural muscles, dynamic balance and
protective reactions.
-Velcro Sandwich Stacking Game: The therapist will ball up soft velcro ingredients such as
lettuce, cheese, bread, ham, etc. and throw them around the therapy room. Gabrielle will have to
retrieve the ingredients by walking backwards, bear walk, skipping, jumping, on the scooter
board, etc. This can be graded by the methods of retrieving the ingredients and by using recipe
cards and having Gabrielle follow them. Gabrielle will then build a sandwich by flattening out
the ingredients, using intrinsic hand muscles and building age appropriate grasps, and put the
ingredients on top of each other. This activity will help prepare Gabrielle to don and doff her
elastic waist pants and additional items of clothing.
-Play Dress up: Dress up can be played using extra layers of clothing on Gabrielle or using dolls
and doll clothes. Specific articles of clothing can be chosen by the therapist that have zippers,
buttons, snap closures, Velcro, etc. to focus on specific skills. By choosing appropriate clothes
this activity can be graded down or up using real or doll clothes. Funny hats, glasses, socks,

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gloves, etc. can be selected. This activity will help prepare Gabrielle to don and doff her own
clothes, specifically her pants, in preparation for toileting and to help her parents with
morning/bedtime routines.
-Lite-Brite: Lite-Brite can be played with the therapist or a family member during the treatment
session. This game will promote age appropriate pincer grasp as well as in hand manipulation
skills. If Gabrielle has a favorite game as well that uses small pieces such as Polly Pocket will
help with fine motor skills as pincer grasp as well.
-Make Jewelry: Gabrielle will string beads of multiple sizes/diameters on a string to make
jewelry of her choice (necklace or bracelet). To grade this up the therapist can decide on the
sequencing and have Gabrielle copy the sequence from oral directions, visual explanations,
memory, etc. This activity will appropriately tax Gabrielles fine motor and in hand manipulation
skills in preparation for handling her cochlear implant, hearing aid and batteries.
-Blow Bubbles: Gabrielle will blow through a straw to make colorful bubbles. Then she will
take a piece of paper and place it on the bubbles to pop them and create bubble art. Not only is
this a play based activity; Gabrielle will get to take home a piece of art that she has created. This
activity can be graded up by using longer, thinner straws. Alternatively, it can be graded down by
using shorter, larger diameter straws. This activity will promote oral-motor skills in preparation
for using an age appropriate cup.
-Blow Cotton-ball Sheep into Barn: Gabrielle will lay on the scooter board in prone and blow
sheep (large cotton balls) using a straw across the gym floor into the barn. She will propel herself
with her legs and arms on the scooter. This can be done solo, as a race with the therapist, another
child, or a family member. This activity will challenge Gabrielles pursuit/tracking,

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accommodation, divergence/convergence, oral motor skills, gross motor, bilateral coordination

and neck extension.
Catch: Gabrielle will play catch with the occupational therapist. In order for Gabrielle to play
catch she must focus on the ball as it comes near her, thus working on convergence. In addition,
playing catch will also work on Gabrielles accommodation abilities as she looks in the distance
at the occupational therapist, and then focuses closer as the ball travels toward her.
Playing with Play dough: Gabrielle will play with play dough as an intervention activity. As
Gabrielle squishes and flattens the play dough, she will work on her intrinsic hand muscle
strength and endurance. Both of which are needed to increase her grasp strength, eventually
allowing Gabrielle to don/doth her elastic waist pants.
Play with Small Rubber Stamps: Using small rubber stamps to create art work will facilitate
Gabrielles precise pincer grasp. Fine motor strength and endurance will also be targeted as
Gabrielle must push the stamp down on the paper in order for the ink to transfer. In addition to
creating general art work with the stamps, Gabrielle can write her name with the stamps or play a
game of tic-tac-toe with her occupational therapist.
The Game of Memory: Gabrielle will play Memory with her occupational therapist in order to
work on her visual memory and fine motor skills. Playing Memory with Gabrielle will provide
an opportunity for Gabrielle to hold not only a visual image in memory, but also the location of
that specific card. When the game is first played with Gabrielle it can be graded down by
limiting the number of cards that must be matched. As Gabrielles visual memory improves, the
game can be graded up by adding more cards to the game. Memory also provides opportunities
to work on fine motor manipulation such as when Gabrielle uses a pincer grasp to flip the cards.
Treatment Session

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This treatment setting will take place in the outpatient clinic where Gabrielle goes for
occupational therapy. It will be a 53-minute session.
Using printed activities pages Gabrielle will have to find the hidden objects amongst
various pictures. Intervention will aim to help Gabrielle recognize and attend to the identifying
features by teaching her to use her vision to locate objects. Cues will be given to teach her to
scan or search the pictures visually and help her find meaning. As Gabrielle looks at the pictures
we will discuss the importance of visually scanning her room and the playground for objects that
she may trip over. The therapist will ask Gabrielle to identify objects in a picture of the therapy
room and then look up from the picture and point to the object in the room. This will help work
on accommodation and convergence/divergence ocular motor skills. Gabrielle will have her
choice of blowing bubbles or blowing different whistles as the therapist prepares for the next
activity.
For the next activity, we will hide objects around the therapy room and have Gabrielle
find them by scanning the room visually. Each time there will be different requirements. One
time she will have to roll herself on a scooter board in prone to find the hidden object promoting
visual scanning from a different perspective, neck extension, upper body strengthening and
bilateral coordination. Another time she will have to talk about everything she sees as she is
looking for the object to help the therapist understand what she is noticing and what she is
missing. One time she may have to crawl or walk backwards. Another time she will have to
safely navigate around objects placed by the therapist to teach safety. Lastly, she will have to find
an object that is hidden underneath multiple layers of clothing. This will require her to use fine
motor skills, unbutton and unzip jackets, and work on motor planning and bilateral coordination.

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Another time Gabrielle will have to walk on the therapy mats and navigate uneven surfaces
around bean bags and on different height mats to find small objects that require a pincer grasp
and she will have to bring them to the therapist and drop them in a cup. This will help to improve
her pincer grasp strength and endurance.
For our last main activity, Gabrielle will lie on a scooter board and blow through a straw
to move cotton balls (sheep) behind their fence. This activity will help Gabrielle work on lip
closure and strength, visual pursuits as well as accommodation, convergence/divergence and
neck extension.
SOAP Note
Subjective: Gabrielle arrived with her Mother and was excited to be at therapy. Gabrielle stated,
Look, I can blow a kiss now.
Objective: Gabrielle participated in a 53-minute OT session in outpatient clinic for increased
independence and safety with play-based occupations. Gabrielle participated in 15 minutes in
therapy gym for skilled instruction of visual scanning and ocular motor skills. Gabrielle required
verbal cues to stay on task and visual cueing to find most objects in the room. Gabrielle
participated in 20 minutes of object hide and seek, promoting variability and problem solving
through visual scanning and environment exploration. Her functional mobility, vestibular and
proprioception skills, visual scanning, fine and gross motor skills, and problem solving were
taxed through methods of finding the object. Gabrielle had to walk backwards, scoot on scooter
prone, crawl, walk on uneven mat surfaces and find objects hidden in layers of clothing.
Gabrielle participated in 15 minutes of oral/ocular motor game (Sheep herding game). She
required verbal cueing and therapist modeling to complete the activity. Gabrielle showed signs of

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fatigue after 10 minutes with neck extension and the game was modified to be played on table
top for last 5 minutes of session.
Assessment: Gabrielle showed poor visual scanning during hidden object picture activity.
Postural facilitation and visual cues provided by the therapist improved visual scanning and
performance. Visual scanning techniques such as pointing with fingers, scanning from left to
right and top to bottom were taught to Gabrielle and she showed improved identification of
objects placed around therapy room. During object hide and seek, Gabrielle showed hesitation
with motor planning, expressed discomfort with prone and crawling, fell on uneven mats twice
and was guarded while transitioning between surfaces. Gabrielle has decreased falls from last
week when this activity was done from 4 to 2 falls. Therapist had to verbally cue and
demonstrate proper pincer grasp and unbuttoning/unzipping techniques after Gabrielle asked for
help. Modifications for sheep behind the fence game were necessary. Game was completed on
table-top. Client began in a prone position for the sheep behind the fence game but the activity
was graded down due to fatigue of patients neck extensor muscles. Patients progress in oral
and ocular motor skills indicates good potential to meet goals as stated in treatment plan.
Gabrielle would benefit from continued skilled OT instruction in ocular and oral motor skills for
successful and safe participation in play and everyday routines.
Plan: Continue skilled OT per treatment plan.

Post-discharge Environment and Recommendations

The client will be discharged into her home and preschool environment. Gabrielle, being
only 3 years and 7 months of age, will spend most of her time with her family at home and will
need to participate in appropriate play and learning in preparation for when she will enter

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Kindergarten. Being introduced into an environment that is conducive to her needs, Gabrielle
will learn appropriate play and learn how she must use her senses to interact and change her
environment so she can participate in social, physical, and cooperative play, despite her
developmental delays. The highest level of concern for Gabrielle is her vestibular instability and
her safety within her environment transitioning from uneven surfaces. By creating an open and
clear floor plan within her home, Gabrielle will have the freedom to move around without any
constraints. Her room will be organized in a way that all of her toys, books, dresser, and bed are
located around the periphery of the room in a sequential fashion. By organizing her room she
will be able to use her tactile and cognitive senses when she feels frustrated about where things
are. This will also help her organizational skills that she will need to be successful in a classroom
environment.
Parental recommendations for Gabrielle include: continued support with dressing when
necessary and implementation of potty training that requires donning/doffing of clothing.
Continuing skilled occupational therapy treatment once a week is also recommended.
Additionally, Gabrielle should be given opportunities to continue to work on fine motor and
dexterity skills through imaginary play of dressing dolls and playing tea party. Parents will need
to facilitate activities in which Gabrielle will be lying in prone positions such as playing with
board games while laying prone or playing on a scooter board. Games such as blowing sheep
(cotton balls) into their barn with straws will enable Gabrielle to strengthen her ability to
maintain her neck in neutral and extended positions. Finally, Gabrielle can continue to
accomplish lip closure through play activities such as blowing bubbles or whistles. This will also
enable her to strengthen her oral motor skills so she can drink from a cup. All of these games and

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activities can be played at home with the entire family. Annual testing for vision and hearing are
recommended for Gabrielle to detect any future progressive sensory loss early.
Justification and Articles Reviewed
Intervention 1: Obstacle Course: According to the study, Balance and Self-efficacy of Balance
in Children with Charge Syndrome, many participants with CHARGE syndrome are at moderate
to high risk of falling and also have low confidence in their ability to maintain balance. Selfefficacy of balance has been show to correlate with increased fall risk and decreased
participation in physical activities. The study found that in order to lower the fall risk of children
with CHARGE syndrome they should improve their dynamic balance through physical activities
that promote movement, strength and flexibility. By using an obstacle course as intervention, it
will allow Gabrielle an opportunity be active and work on her dynamic balance as she shifts her
weight and balance to avoid obstacles.
Intervention 2: Lip Closure & Jaw Stability: In order to facilitate Gabrielles ability to drink
from a cup & use a straw, activities are focused on increasing her lip closure and jaw stability. In
a study by Gisel (2008), lip closure is facilitated through various sensorimotor interventions and
jaw stability is vital for competency in drinking from an open cup. Therefore, treatment activities
for lip closure include sucking on jolly rancher lollipops and holding a Popsicle stick between
the lips. Improvement in jaw stability will be accomplished indirectly by strengthening the jaw
muscles through play with whistles and blow toys.
Intervention 3: Visual Training: According to the initial findings of an article in Gait &
Posture, visual training improves obstacle avoidance in older adults (Reed-Jones, Dorgo,
Hitchings, & Bader, 2011). These finding have been generalize for application with Gabrielle.
Visual scanning for obstacle avoidance is a primary goal for Gabrielle to ensure her safety.

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Interventions like finding hidden objects in the room will work on her saccades and
accommodation as she searches for the items.

References
Case-Smith, J., OBrien, J. (2010). Foundations for Occupaitonal Therapy Practice with
Children. Law, M., Missiuna, C., Pollock, N., Stewart, D. Occupational Therapy for
children (pp.33-38). Maryland Heights, Missouri: Mosby Elsevier.

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Case-Smith, J., OBrien, J. (2010). Sensory Integration. In Mailloux, Z., Parham, D. L., (6th
ed.), Occupational Therapy for Children (pp. 325-372). Maryland Heights, Missouri:
Mosby Elsevier.
Case-Smith, J., OBrien, J. (2010). Application of Motor Control/Motor Learning to Practice. In
OBrien, J., Williams, H., (6th ed.), Occupational Therapy for Children (pp. 253-257).
Maryland Heights, Missouri: Mosby Elsevier.
Gisel, Erika. Inverventions and Outcomes of Children with Dysphasia. Developmental
Disabilities Research Reviews, 14, (pp.165-173).
Haibach, P.S., & Lieberman, L.J. (2013). Balance and Self-efficacy of Balance in Children with
CHARGE Syndrome. Journal of Visual Impairment & Blindness, 107(4),( pp.297-309).
Reed-Jones, R.J., Dorgo, S., Hitchings, M.K., & Bader, J.O. (2012). Vision and agility training in
community dwelling older adults: incorporating visual training into programs for fall
prevention. Gait & Posture, 35(4), 585-589. doi:10.1016/j.gaitpost.2011.11.029
Schell, B.A.B, Gillen, G., & Scaffa, M.E. (2014). Ecological Models in Occupational Therapy.
Brown, C. (12th ed.) Willard & Spackmans Occupational Therapy (pp.494-503).
Philadelphia: Lippincott Williams & Wilkins.