Occupational Therapy Case Study

Case profile

The client:

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Tim* was a ten-year-old male with no formal diagnosis.

Previous relevant medical history:

Tim was born at 35 weeks and remained in intensive care for six months post birth. This is relevant as a pre-term birth increases the risk of delayed neurodevelopment (Schieve et al., 2016) with a recent study also suggesting that functional limitations in activities of daily living (ADLs) “do not appear to self-correct and could lead to poorer educational attainment” (Killeen et al., 2014, p.304) in children who were born pre-term.

There are no other aspects from the details provided of Tim’s medical history which were relevant to the occupational therapy process.

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Family status:

Tim was an only child. Tim’s mother was on leave from her job as a nurse as she was undergoing treatment for early stage breast cancer of which the prognosis was quite positive (Harbeck and Gnant, 2017), however this did cause Tim’s mother acute fatigue. Tim’s father was employed on a full-time basis by a local construction company. The family was not in receipt of formal support within the home at the time. Tim often was required to assist in the running of the home, e.g. completing household chores.

School:

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Tim attended a local primary school with fewer than forty children in attendance overall. Tim’s mother noted in the referral form that Tim did not receive formal support within the school, e.g. resource hours, however, as the class was small, the class teacher was able to provide Tim with increased assistance as required.

Leisure:

Tim enjoyed playing football after school with the local club and travelled to training with a friend who lived nearby however he often missed football training due to time spent completing homework tasks. Tim also enjoyed drawing pictures.

Reason for referral to occupational therapy:

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After discussion with Tim’s parent’s and with their informed consent, the class teacher referred Tim to occupational therapy. The class teacher identified concerns relating to Tim’s motor skill development and handwriting ability.

Parental concerns as identified on the referral form (in order of priority):

1. Tim’s handwriting was illegible and his speed of production was very slow. This was preventing him from participating adequately in class activities which he enjoyed, e.g. story writing.
2. Tim was unable to tie the small buttons on his school shirt.
3. Tim had difficulty completing drawing tasks, which he enjoyed, due to hand fatigue.

Model of Practice

The model of practice chosen was the Person – Environment – Occupation and Performance model (PEOP, Baum, Bass-Haugen and Christiansen, 2005). The PEOP model is a client-centered model, which links with current occupational therapy practice guidelines outlined in the Occupational Therapists Registration Board Code of Professional Conduct and Ethics Bye-law 2014 that emphasise client-centred practice as central to occupational therapy. However, in the context of the approach to Tim’s care, “family-centred care, which recognizes the importance of including the family in a child’s care [and] is currently the most well-established approach to health service delivery for children” (Hayles et al., 2015, p.1) must also be applied, which using the PEOP allows for, due to the model’s design (Lee, 2010). The model also considers the family, which in Tim’s case is a hugely influencing factor on the occupational therapy process and how they can act as facilitators or barriers to Tim’s occupational performance (Baum, Bass-Haugen and Christiansen, 2005).

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A primary reason for choosing the PEOP model was that it allowed for service requirements to be met whilst ensuring that the therapist maintained an occupational perspective (Joosten, 2015, p.221). Models such as the Model of Human Occupation (MOHO, Kielhofner, 2008) are process-based and are based upon the theory that changing a client’s intrinsic factors will cause an improvement in occupational engagement (Wong and Fisher, 2015). The PEOP model is a ‘top-down’ model but it also allows for analysis of the underlying factors (i.e. person factors and environment factors) which contributed to the limitations in occupational participation (Wong and Fisher, 2015); thus enhancing the therapist’s knowledge of the nature of the occupational problem, whilst also allowing the occupational therapist to adhere to service requirements which dictated a need for the assessment of performance components. The occupational therapist could then apply the knowledge of the performance components, e.g. Tim’s in-hand manipulation skills, to enrich the therapists overall image of the context of Tim’s participation in occupation. This subsequently allowed for occupation-focused goals to be collaboratively set with the client. 

Initial assessment