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Running head: CASE STUDY ANALYSIS-SHELLY

Case Study Analysis-Shelly


Heather Pantea
Saginaw Valley State University
OT 535

Case Study Analysis-Shelly


Medicinal and Developmental Background
This case study focuses on an 8 year, 11 month old individual named Shelly.
Shelly has been reported to have typical development until recently when she was
evaluated for issues with attention, focus, and completion of assigned school work.
Evaluation findings point towards possible multiple diagnoses which include ADHD,
hypotonia, and dyspraxia.
ADHD
Attention deficit-hyperactivity disorder (ADHD) is defined as the most common
childhood neurobehavioral disorder that can continue into adolescence and even
adulthood (Rogers, 2010). While symptoms in ADHD vary and are individualized, there
are specific presentations of behavior that indicate an individual may have ADHD. These
symptoms include inattention, hyperactivity, and impulsivity (Rogers, 2010). In Shellys
case, she may be exhibiting the symptom of inattention through her difficulty of staying
on task for homework assignments, disorganization of her personal belongings, and being
unaware when she has leftover food on her face after meals.
Although hyperactivity is not as strongly observed in Shelly, she seems to present
the symptom of impulsivity through multiple behaviors. Shellys emotional instability
(e.g. temper tantrums, sensitivity to criticism, crying easily), low tolerance of frustration,
feeling anxious and expression of feeling like a failure (which indicates low self-esteem)
may all be considered indicative aspects of impulsivity. Additionally, she has issues with
peers her age ridiculing her because of her inability to understand social cues.
Hypotonia
Hypotonia is considered to be abnormal muscle tone in an individual, in which the
muscle tone is reduced or low in an individuals extremities (Preston, 2013). Because of

Case Study Analysis-Shelly


this decreased tone, an individual may have trouble moving limbs in an efficient and
functional manner (Preston, 2013). Shelly has been reported to have awkward
movements in comparison to her peers as well as accident prone. Even though she has
been reported to initiate movement frequently and finds movement enjoyable, her
insufficient muscle tone may be influencing her abilities to participate in activities due to
weakness caused by her hypotonia.
This condition may also explain why Shelly necessitates assistance for simple
daily activities such as combing her hair and dressing herself. She may be experiencing
frustration and feelings of inadequacy due to her inability to participate in normal
movement. Her hypotonia could also be impacting her issue of not being able to grow
up; forcing her to rely on others for assistance in daily activities she has trouble with that
typical children her age do not have problems with.
Shellys choice of interacting and socializing with younger children that are
developmentally behind her may be a direct result from her hypotonia. By engaging with
younger peers, Shelly may feel she is at a level in which she feels more accepted instead
of feeling behind when she interacts with others her age that are able to participate in
typical functional movements.
Dyspraxia
The ability to plan and carry out a motor task or activity is referred to as praxis;
dyspraxia is defined for a child as having problems with this praxis in spite of normal
environmental conditions and not as a result of a medical disability (Parham & Mailloux,
2010). While dyspraxia may be independent as its own diagnosis, it can be combined
with other issues seen in children. Dyspraxia is included in the category of motor

Case Study Analysis-Shelly


dysfunction under the grander scheme which refers to learning disabilities. Learning
disabilities affect a childs ability to process information, communicate, master schoolrelated tasks, and are often seen with other neurological problems such as ADHD
(Rogers, 2010).
The issue is not Shellys capacity to learn as she has reported above average
scores in academic and mental skills, which in many cases children with learning
disabilities present normal or above average intelligence (Rogers, 2010). Shellys
problem areas pertain to how she executes her motor skills, which may also be coupled
with her impaired function due to her hypotonia. The report indicated that she has issues
in interaction with objects (e.g. choosing not to use silverware when eating) and
manipulation. Even if she has a failed attempt at that interaction, she will not change her
approach to produce a different outcome. Her confrontations with new situations or
transitions between environments may also be negative because of her lack of ability to
plan her functional movements, which may be leading to her hesitance, lowered
confidence, poor emotional stability, and necessity for encouragement and prompting.
Occupational Assessment
Areas of Occupation
When referring to the Occupational Therapy Practice Framework: Domain &
Process II, Shelly exhibits issues in varying areas. One of the domains to be considered is
her areas of occupation. In her activities of daily living (ADLs), Shelly has been
reported to experience problems in the areas of dressing (needing assistance with socks),
feeding (not using silverware, leaving food on her face), and personal hygiene and
grooming (combing her hair). Her report also indicates that she experiences issues with

Case Study Analysis-Shelly


education (formal educational participation in assignments), play (participation in
immature play), and social participation (engagement with younger peers instead of peers
her age).
Performance Skills
Another domain to examine is Shellys performance skills. Shellys skills that are
impacted through her multiple diagnoses are her motor and praxis skills (e.g. awkward
movement, unable to find the best way for a problem), emotional regulation skills (e.g.
temper tantrums, low frustration tolerance), cognitive skills (e.g. organizing personal
belongings, recognizing when it is time to transition between environments), and
communication and social skills (e.g. trouble with recognition of social cues).
Performance Patterns
Shelly has a few distinct roles she is involved with on a daily basis. These roles
include being a daughter, student, classmate, and friend. Her diagnoses of ADHD,
hypotonia, and dyspraxia may be impacting each of those roles substantially. Her routines
(e.g. getting ready for school) may also be impacted by symptoms of her ADHD, her
inability to plan functional movement, and muscle tone. Some habits that were included
within Shellys report was her persistence and continuation to use one solution in regards
to object interaction and manipulation even if it proves unsuccessful, consistently
choosing younger peers to play with, and being unable to keep her personal belongings
organized.
Client Factors
Shellys affected client factors pertain mostly to her body functions and body
structures. Shellys neuromuscular and movement-related functions are an area of

Case Study Analysis-Shelly


concern in regards to her muscle tone. Her body structures may also be of concern
pertaining to her structures related to movement (her extremities). Although many of the
issues seen in Shelly deal with her physical aspects, there are also concerns with her
client factors in the area of values. Looking at her report, Shelly seems to value play,
leisure activities such as reading, and spending time with others. While Shelly has not
expressed concerns with her homework, her parents have indicated that they value her
intellectual capacities and wish for her to improve her skills in completing her school
work on her own accord. Her parents have also stated they have noted issues with her
expression of emotions and communication skills and wish for her to be able to
communicate effectively and act her own age, indicating they value Shelly being able to
act at an appropriate age level. Shelly also seems to exhibit this value, alluding to this
through her expression of feeling like a failure from the impacts of her conditions.
Assessments Chosen
There are many areas which need to be addressed in Shellys case. The issues
lying within her areas of occupational performance, performance skills, performance
patterns, and client factors must all be taken into account. For this case, six assessments
have been chosen to tackle Shellys areas of deficit and concern.
One of the assessments to be used to address Shellys areas of occupational
performance is the Perceived Efficacy and Goal Setting System (PEGS) (Missuna,
Pollock, & Law, 2004). This assessment focuses on a childs abilities in daily activities
from the aspect of the child, parents, and teacher. Using this assessment will assist
therapist, parents, and teacher to collaborate on goals for Shelly to reach, which may
include focus on Shellys issues with ADLs, education, play, and social participation. By

Case Study Analysis-Shelly


allowing participation of child, parents, and teacher, Shellys home and school
environmental contexts will be included. Shellys roles, habits, and routines (performance
patterns) are also addressed with this assessment with the centrality being on the childs
abilities within the school and home environment.
The next assessment to be used will focus on an area of Shellys performance
skills and client factors; particularly her motor skills and function and value of being able
to engage in activities such as social participation. Bruininks-Oseretsky Test of Motor
Proficiency, 2nd Edition is a comprehensive assessment designed to examine both gross
and fine motor skills (Bruininks & Bruininks, 2005). Because Shelly has hypotonia and
dyspraxia, she has issues using motor skills to the best of her ability. Her deficits in these
areas may also be contributing to her frustration and emotional instability, as well as
choosing peers to interact with that are more developmentally on her level. Identifying
specifically the skills Shelly struggles with will assist in treatment and intervention
planning with a special focus on education planning. By including an educational
component, Shelly will be assessed in comparison to peer norms to determine her
developmental status (by use of age equivalence scores), strengths, and weaknesses.
Another assessment to be used that includes a focus on praxis and social
participation skills is the Sensory Processing Measure (SPM) (Parham, Ecker, Kuhaneck,
Henry, & Glennon, 2007). This measure includes both a home and a school form, so
differences in observation will be included in scoring according to the home form
completed by the parents and the school form by the childs teacher. This assessment
pertains to Shellys case in regards to her social participation skills (performance skills)
and also to her dyspraxia (client factor of body functions). Examining these factors may

Case Study Analysis-Shelly


assist in further reading into Shellys emotional regulation skills, communication skills,
and cognitive skills, which would be supportive in designing and implementing
intervention plans. The SPM may not address specific areas of occupation; however, it
does take into account how behaviors can affect function in different aspects of daily
living. Therefore, this assessment can also be used to assess specific areas of occupational
performance that Shelly may be struggling the most with.
An assessment that pertains particularly to Shellys diagnosis of ADHD is the
Conners Rating Scales, Revised, which focuses particularly on behaviors that cause
issues within the child (such as cognitive issues, emotional issues, and anxiety issues)
(Conners, 1997). This assessment encompasses many of the performance skills and client
factors that Shellys report includes as her problem areas due to her diagnosis of ADHD.
The Conners Rating Scales, Revised also addresses Shellys performance patterns in
how she currently copes and adapts in her daily life (as a daughter, student, and peer)
with her condition of ADHD. By identifying specific areas in which Shelly has deficits in
explicit to ADHD, exact measures can be taken in intervention to address these issues.
One of the areas that were most highlighted in Shellys report was her problems
with attention. An assessment that focuses precisely on attention issues is the Test of
Everyday Attention for Children (TEA-Ch) (Manly, Robertson, Anderson, Nimmo-Smith,
1999). This measure tests a childs skills in attention that have an impact on everyday
behavior. In the context of Shellys case, TEA-Ch may be useful in determining in which
areas of attention Shelly has precise issues with. This assessment is also useful in Shellys
case in terms of using her attention capacities presently to reach goals set in intervention
planning through improving her attention skills. Shellys performance skills and client

Case Study Analysis-Shelly


factors are also addressed in this assessment. This includes her attention skills necessary
to participate in many activities, such as completing homework assignments, her
preferred activity of reading, and recognizing social cues in interaction.
While there are perceptions gathered on Shellys overall condition from her
parents, teachers, and medical personnel, it is important to also gain Shellys perspective
of how she feels. While this is somewhat done through the PEGS assessment, this focuses
primarily on daily activity performance. The Self-Esteem Index (SEI) addresses Shellys
feeling like a failure, as well as her anxiety and emotional instability (Brown, &
Alexander, 1991). Client factors and performance skills that are relevant to this
assessment are her emotional regulation skills, as well as the value of her being able to
act her age. Responses to the assessment may also be used to assess Shellys roles, habits,
and routines and how she feels these areas are affected. The SEI is used at the beginning
of treatment to indicate personal and/or social problems that might be an important area
of focus when designing an intervention plan. By having Shelly engage in this
assessment, the center of her treatment remains on areas that are most significant and
relevant to her life.
Treatment Plan
Areas of Concern
Based on looking at Shellys report, there are specific areas of concern that should
be prioritized in her case. Shellys ability to functionally perform in multiple areas of
occupation has been affected largely by her low muscle tone, inability to plan her
movements, and difficulty to focus. She also struggles with emotional regulation and
communication, as well as issues with social interaction with peers. Overall, the chosen

Case Study Analysis-Shelly


main areas of focus for Shelly are as follows: improving motor control (both gross and
fine), being able to function independently in occupational tasks, and improving selfregulation and attention skills. By focusing on these three areas, Shelly will
simultaneously be working on skills that affect her social participation, school life (e.g.
homework assignments), and home activity (e.g. ADLs/IADLS). Through improvement
of these skills, Shellys self-esteem and confidence will likely be increased as well.
Additionally, Shellys roles, habits, and routines as well as her client factors will be
impacted by focusing on treating the issues which cause deficits in these areas.
Goal One- Improve Motor Control
In the case of Shelly and improving her motor control in terms of gross and fine
motor movement, focus on this area will address Shellys condition of low muscle tone
due to her hypotonia. A long-term goal which would involve gross and fine motor
movement for Shelly would be: Shelly will complete her morning hygiene and grooming
routine independently.
The main frame of reference and theoretical background this goal stems from is
the neurodevelopmental treatment approach (NDT) used in the field of occupational
therapy. The theory of NDT revolves around the belief that typical movement can be
learned by those who currently suffer from neuromotor challenges and exhibit atypical
movement patterns, therefore causing change within the central nervous system through
the elements of the person, environmental context, and task (Barthel, 2010).
In this frame of reference, specific techniques are utilized to instill changes in
how a child moves (Barthel, 2010). The primary technique of NDT is therapeutic
handling, in which the therapist places their hands in key points of control on the childs

Case Study Analysis-Shelly


body to impact posture and movement and can be used while a child is engaging in
activity (Barthel, 2010). In Shellys case, her hypotonic state will differ from a child who
has spastic or hypertonic muscle tone. According to Barthel (2010), a child who suffers
from hypotonia benefits from antigravity positions (such as sitting or standing) with
controlled movements in a limited range of movement. For example, Shelly could engage
in activity (such as picking up different sized balls off the floor) sitting on an exercise
ball while functional movements are facilitated at key points of control (e.g. scapula),
simulating different tasks that emulate movements used in functional daily activities (e.g.
picking up a comb, squeezing toothpaste out of a tube).
While the goal of this treatment is improved motor control, it is important to
remember that play should be included in an intervention for a child to be successful. In
the article Integrating Play in Neurodevelopmental Treatment, (Anderson, Hinojosa, &
Strauch, 1987) use of play materials in the environment and use of self as a play agent are
significant aspects when incorporating play as motivation when using NDT with children.
Using play activity can help translate movements learned and used to other areas, such as
daily occupational activities (Anderson, Hinojosa, & Strauch, 1987). In terms of Shellys
condition, by using/manipulating objects (e.g. different sized balls), facilitative,
functional movement (done by handling), and play activity (in which skills can translate
to other areas of occupation), she can use these abilities in areas which she struggles with,
such as grooming. Furthermore, once Shelly has attained the goal of independently
completing her morning hygiene and grooming routine, she may be able to use her
abilities in this occupational activity in other daily activities, such as dressing. If Shelly is

Case Study Analysis-Shelly


able to successfully complete activities independently, her self-esteem will most likely be
impacted positively as well.
Goal Two-Functioning Independently in Occupational Tasks
While it was somewhat discussed in the previous goal of improving motor control
that an impact of that goal could be improved independence in activities, Shelly still has
the issue of dyspraxia which can affect her planning of functional motor movements and
participating in occupational activities (even if she has the motor capability). This is
reasoning why a priority should be placed on Shellys abilities to self-initiate and carry
out activities needed to be done in her daily life.
A goal for Shelly in this area might be constructed as so: Shelly will keep her
personal belongings organized at home and school. While organization of multiple
belongings may be overwhelming to take on, it would be beneficial in this case to focus
on certain area or activity to begin. For intervention with Shelly, incorporating items that
she enjoys may be beneficial when starting treatment.
For example, Shelly values and enjoys the activity of reading but has issues with
the motor activity of organizing her belongings. Her belongings may include books she
has at home. At her age, children usually possess the ability to organize belongings
independently. Because Shelly is unable to plan her movements and execute a movement
properly (e.g. picking up a book and placing it in its designated area), she seems to
require more structure when engaging in an activity.
The frame of reference, Cognitive Orientation to Daily Occupational Performance
(CO-OP) deals precisely with learning new motor skills and how to attain those skills
through various measures. Polatajko, Mandich, and McEwen (2012) discuss how this

Case Study Analysis-Shelly


frame of reference is a client-centered approach, allowing the individual being treated to
choose goals to reach that he or she considers important. Because this approach focuses
on motor-based performance problems (in which Shelly has both dyspraxia and
hypotonia), it addresses many of the areas which Shelly has deficits in (functional motor
movement, planning to reach a motor-based goal, and focusing on a specific task).
Additionally, CO-OP applies to Shellys case again in that it is a learning-based
intervention frame of reference which requires the individual being treated to actively
engage and be motivated to reach the chosen goals (Polatajko, Mandich, and McEwen,
2012).
By using a goal-oriented activity that combines Shellys value of reading and her
parents value of participating in activities that are Shellys responsibility, Shelly is able
to plan a goal, make a plan to reach that goal by breaking it into attainable components,
and check to see if she successful at the end by means of her motivation/meaning
associated with the activity of reading. CO-OP involves many factors, which include
feedback (both extrinsic and intrinsic), enabling principles, support systems, and domain
specific strategies (focusing on a part of a task) (Polatajko, Mandich, and McEwen,
2012). This may include feedback from Shellys parents, therapist, and herself, learning
how to use strategies in other areas of life once skills have been attained, supporting
figures (e.g. parents) if encouragement is necessary, and learning to find strategies that
support engagement in the task (e.g. using a visual encouragement/cue card to assist in
completion of the task/goal).
As a cognitive approach to learning skills that support independent function, COOP is useful in attaining long-term goals and helping the individual being treated transfer

Case Study Analysis-Shelly


skills learned to other areas of life (Ayyash & Preece, 2003). Through use of this frame of
reference, Shelly will learn how to attain goals by use of her own planning and skills. By
starting with shorter-term goals (such as organizing her personal books on her own
bookshelf), she will gain the knowledge and skills to reach more long-term goals. For
reaching her short-term goal of organizing her books, she may do this by breaking the
task into smaller components (e.g. group books together to sort, start with books
beginning with a specific letter, etc.) and learning how to motivate herself through the
task (e.g. visual encouragement card, talking herself through the activity). When Shelly
reaches a functional goal that applies to specifically to areas of her life, she will have the
confidence and improved ability to apply those skills to other areas of life she struggles
with. This could include organization of all belongings at school and home or completing
homework assignments without continued encouragement and prompting.
Goal Three-Improve Self-Regulation and Attention Skills
Last but not least, Shellys areas of deficits also include her attention and
emotional regulation skills. Primarily, these areas seem to be most affected by her
condition of ADHD, although some symptoms may be results of her other conditions of
hypotonia and dyspraxia. Because Shelly has trouble communicating her emotions and
picking up on social cues when interacting with others, it is important to address these
issues in regards to her underlying inattention and impulsivity problems.
A long-term goal that encompasses this may be: Shelly will engage in social and
play activity with age appropriate peers. While Shelly is social seeking, she has trouble
interacting with peers her age due to her inattention and emotional over-responsiveness.

Case Study Analysis-Shelly


A frame of reference that incorporates working towards changes in social participation,
self-regulation, and attention to the environment is the sensory integration approach.
The developer of this approach, A. Jean Ayres, postulated that children with
learning and behavior problems lack the adequate processing and integration of sensory
information coming from the environment to adapt appropriately (Schaaf et. al. 2010).
Because Shelly has ADHD concurrently with a learning disability (dyspraxia) and a
motor disability (hypotonia), she is unable to use input coming in from her various senses
to act appropriately, both in attention and emotional aspects. Sensory integration is
designed on the theory that children seek meaningful experiences through sensory input
and that sensory integration is necessary for engagement in physical and social aspects, as
well as participation in activities of daily life (Schaaf et. al. 2010). How this can be
addressed in Shellys case is helping her to realize adaptive behaviors she can utilize
when she starts to feel overwhelmed and upset, as well as communicate with her peers in
a manner that they understand her feelings and she can pick up on social cues.
In a study conducted by Miller, Coll, and Schoen (2007), occupational therapists
set up a structured environment in which the child being treated can choose from various
toys and activities that are sensory-based to create a pretend situation and interact with
the objects in a meaningful approach. By doing this, Shelly can obtain specific sensory
input from varying tools while being in control of the environment, helping her to realize
she can regulate and control herself in the environment through interaction. Because this
approach includes challenges and scaffolding as well, Shelly is able to adapt and regulate
her behavior (in regards to social participation, motor competence, and participation in

Case Study Analysis-Shelly


meaningful occupation) to different scenarios she may encounter in every day life
(Miller, Coll, & Schoen, 2007).
Modifications to the environment can also be a viable option in the sensory
integration approach. In a case study conducted specifically on a child with the diagnosis
of ADHD, modification to the environment (which included having a helpful peer at
school, eliminating sensory overload, etc.) is also useful when seeking to increase
participation and assist the individual being treated with emotional responses to sensory
input (Young, 2007).
By use of sensory integration, Shelly can improve her social and play
participation skills with age-appropriate peers (e.g. increase attention to social cues),
communicate better when she feels overwhelmed and sensitive, and use adaptive
techniques to help regulate her emotions. If Shelly feels she has more control over her
emotional responses and attention skills, she will likely also feel more confident and have
an improved self-esteem.
Conclusion
Through treatment and reassessment, Shelly will have the opportunity to improve
her abilities in the areas affected by her conditions. By reaching long-term goals through
intervention, Shelly will gain confidence and skills to cope with her symptoms and
deficits as she continues to develop.

Case Study Analysis-Shelly


References
Anderson, Jill, Hinojosa, Jim, & Strauch, Carrie. (1987). Integrating play in
neurodevelopmental treatment. American Journal of Occupational Therapy,
41(7): 421-426.
Asher, I. E. (Ed.). (2007). Occupational therapy assessment tools: An annotated index
(3rd ed.). Bethesda, MD: AOTA Press.
Ayyash, Hani F. & Preece, Philip M. (2003). Evidence-based treatment of motor coordination disorder. Current Paediatrics, 13: 360-364.
Barthel, Kimberly A (2010). A frame of reference for neuro-developmental treatment. In
Kramer and Hinojosa (Ed.). Frames of Reference for Pediatric Occupational
Therapy (pg. 187-233). Wolters Kluwer: Lippincott, Williams, & Wilkins.
Brown, L., & Alexander J. (1991). Self-Esteem Index. Austin, TX: Pro-Ed., Inc.
Bruininks, R.H., Bruininks, B.D. (2005). BOT2. Bruininks-Oseretsky Test of Motor
Proficieny Manual (2nd ed.). Bloomington, MN: Pearson.
Conners, K. C. (1997). Conners rating scales, revised. North Tonawanda, NY: MultiHealth System Inc.
Manly, T., Robertson, I.H., Anderson, V., Nimmo-Smith, I. (1999). Test of everyday
attention. London, United Kingdom: Pearson.
Miller, L. J., Coll, J. R., & Schoen, S. A. (2007). A randomized controlled pilot study of
the effectiveness of occupational therapy for children with sensory modulation
disorder. American Journal of Occupational Therapy, 61, 228238.
Missuna, C., Pollock, N., & Law, M. (2004). Perceived efficacy and goal setting system.
San Antonio, TX: Pearson.
Parham, D., Ecker, C., Kuhaneck, H., Henry, D., & Glennon, T. (2007). Sensory
processing measure. (5th ed.). United States of America: Western Psychological
Services.
Parham, Diane L. & Mailloux, Zoe (2010). Sensory integration. In Case-Smith and
OBrien (Ed.). Occupational Therapy for Children (pg. 325-372). Maryland
Heights, Missouri: Mosby Elsevier.
Polatajko, Helene J., Mandich, Angela, & McEwen, Sara E. (2011). Cognitive orientation
to daily occupational performance (CO-OP): A cognitive-based intervention for
children and adults. In Katz (Ed.) Cognition, Occupation, and Participation
Across the Lifespan: Neuroscience, Neurorehabilitation, and Models of
Intervention in Occupational Therapy (pg. 299-319). AOTA Press.

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Preston, Linda Anderson (2013). Evaluation of motor control. In Pendleton and SchultzKrohn (Ed.), Pedrettis Occupational Therapy: Practice Skills for Physical
Dysfunction (pg. 461-488). St. Louis, Missouri: Elsevier Mosby.
Rogers, Sandra L. (2010). Common conditions that influence childrens participation. In
Case-Smith and OBrien (Ed.), Occupational Therapy for Children (pg. 146-192).
Maryland Heights, Missouri: Mosby Elsevier.
Schaaf, Roseann C., Schoen, Sarah A., Roley, Susanne Smith, Lane, Shelly J., Koomar,
Jane, & May-Benson, Teresa A. (2010). In Kramer and Hinojosa (Ed.). Frames of
Reference for Pediatric Occupational Therapy (pg. 99-186). Wolters Kluwer:
Lippincott, Williams, & Wilkins.
Young, Rhona Lee (2007). The role of the occupational therapist in attention deficit
hyperactivity disorder: A case study. International Journal of Therapy and
Rehabilitation, 14(10): 454-459.