NORTHLAND COMMUNITY AND TECHNICAL COLLEGE

OCCUPATIONAL THERAPY ASSISTANT PROGRAM

Psychosocial Fieldwork Case Study/Treatment Plan: 45 points
Fantastic Job.
I just realized when grading this, that the wrong treatment plan was uploaded. Thus, I adjusted the points accordingly. As the total is out of 30.

Case Study – Complete the following Chart

All information is included, detailed, organized, professional, no errors/appropriate grammar (5 pts.)
Age and Identifying Information: CJ is a 3-year-old male who has been diagnosed with Autism Spectrum Disorder and a developmental delay.

Description of Diagnosis: State what it
is and describe the diagnosis. Cite your
sources.
Pertinent information in treatment of
Diagnosis: Identify anything that needs
to be considered or taken into account
with this diagnosis. Any Precautions,
concerns, etc. that need to be followed.
Autism Spectrum Disorder (ASD): According to the National Institute of Mental Health (2016), Autism is a developmental
disorder that can range from a high to low functioning level; for example, how severe their symptoms are. The National Institute
of Mental Health (2016) states that some characteristics people with ASD have are the following:
-Ongoing social problems that include difficulty communicating and interacting with others
-Repetitive behaviors as well as limited interests or activities
-Symptoms that typically are recognized in the first two years of life
-Symptoms that hurt the individual’s ability to function socially, at school or work, or other areas of life
Developmental Delay: According to Michigan Medicine (2017), a developmental delay is when a child doesn’t meet a
developmental milestone according to their age. They further state that the delay needs to be impacting their daily lives in a minor
or major way to be considered a developmental delay. Furthermore, a developmental delay is caused by many things, for
example, genetic disorders, prematurity, infant infections.
Michigan Medicine. (2017). University of Michigan Health System. Retrieved October 03, 2017, from
http://www.med.umich.edu/yourchild/topics/devdel.htm
National Institute of Mental Health. (2016). Autism Spectrum Disorder. Retrieved October 03, 2017, from
https://www.nimh.nih.gov/health/topics/autism-spectrum-disorders-asd/index.shtml
Autism Spectrum Disorder: Behavioral concerns and lack of social interaction skills
Developmental Delay: Cognitive delays, gross and fine motor delays

Type of Setting: CJ goes to an outpatient pediatric therapy clinic and attends occupational therapy once per week for 30 minutes. CJ will attend
Frequency/Duration of OT: occupational therapy for 6 months and then a re-evaluation will be done to see if he can be discharged.

Client’s assets: CJ has made good progress and is improving in the areas he is lacking in. CJ can feed himself, use utensils, is potty trained and
has good fine and gross motor skills.

Psychosocial Treatment Plan

Purpose: __/75/5
Excellent job
1. Write a brief description of why this treatment plan is needed , discuss the client’s problems that make you feel this
with this
treatment and the goals established are necessary. (2 pts.)
 This treatment is needed in ord er for CJ to be independent with the areas of occupation. A long with being diagnosed with section! Keep
Autism and developmental delays, CJ lacks cognitive abilities and has behavioral difficulties. This t reatment can allow CJ doing this for
to become as fully functional as he can be through doing meaningful and purposeful activities. He can work towards his all of your
goals of being independent with self -care skills, fine motor skills, cognition, sensory processing skills and visual percep tual treatment
skills. plans!.

2. Go through the OTPF and identify the weaknesses in each area and the items that are a reason for this treatment plan.
Describe why the client has a deficit in the different areas you choose
a. Occupations Excellent job with identifying and describing!
ADLs-Dressing-CJ’s lack of cognitive abilities interferes with his ability to dress himself . CJ cannot independently
do upper or lower extremity dressing.
Play-CJ’s diagnosis of developmental delays and Autism interferes with his ability to play. He doesn’t show interest
in exploring different toys. CJ needs direction from caregivers or therapist to play with toys or which toys to play
with. He doesn’t participate in play with other children every day.
Social Participation-CJ’s behavioral difficulties along with Autism interferes with his ability to listen to and follow
directions that are given to him. CJ also lacks social interaction skills, especially with people he does not know
which can be due to his anxiety also.
b. Client Factors
Attention-CJ’s diagnosis of Autism causes him to have difficulties with staying on task and following directions. He
has behavioral concerns and at times will not follow directions caregivers or therapist.
Emotion-CJ’s behavioral difficulties along with Autism interferes with his ability to successfully regulate with own
emotions.
Vestibular functions-CJ is hyposensitive with vestibular functions. He is constantly seeking out vestibular input by
spinning around in circles.
c. Performance Skills
Attends-CJ is unable to independently complete a task without looking away or interrupting the ongoing task
progression.
Initiates-Usually CJ is unable to begin the next action or step without hesitation. He will not explore different play
toys and he usually needs guidance when playing with toys or with which toy to play with next.
Sequences-CJ is unable to independently perform steps in a n effective or logical order when doing a task. He will
lose concentration or get distracted within the environment he is in.
Expresses emotion-At times, CJ does not express his emotions in a way that is socially appropriate. CJ cannot
independently regulate his emotions as a result of Autism and lack of cognitive abilities.
d. Performance Patterns (4 pts.)
 Role-Student role: CJ’s diagnosis of Autism affects his education, because he loses his concentration when doing
tasks, he doesn’t interact a lot with other kids and he doesn’t always follow directions.
Role-Son: CJ has some behavioral concerns as a result of his Autism. CJ usually doesn’t follow directions at home.
Routine-daily routine: CJ is a concrete thinker when it comes to a daily schedule he does not like change. CJ knows
what is supposed to be happening next and when.
3. Discuss the problems and or concerns with the Context and Environment as it relates to this treatment and goal. (1 pt.)
Cultural-CJ doesn’t always follow cultural norms of behavior al standards. He doesn’t follow directions well and has other
behavioral concerns. These treatment techniques will assist him becoming functional with his emotional regulation.
Physical- CJ is a concrete thinker and his environments get changed up between parents. His goals of following directions
in order to help him follow directions at home can help him with listening and being adaptable to change.
Social-CJ’s diagnosis of Autism and anxiety affects the way he engages in social participation. H e doesn’t engage in play
nor does he play with other children often. Treatment techniques, such as playing board games with the therapists or in
groups will help his social interaction skills and displaying appropriate behavioral within his social environ ment.

Total Points: All above must be present and appropriate, written professionally, minimal to no grammar/writing errors.
Identify the top 2 problems and Create appropriate goals for OT Treatment (STG/LTG for each area). ___31.5/1.5 –
Develop a GOAL using SMART: excellent job
Simple/Specific , Measureable, Achievable/Action Orientated, Realistic/Relevant, Time Bound with goals!
Total Points: Goal(s) must meet the above requirements and be appropriate for individual, written professionally, with minimal to
no grammar/writing errors.

Problem #1: (.50 pt.) STG#1 (.50 pt.)

Client can’t dress himself independently as a result of developmental
delays. Child will be able to doff T-shirt and donn socks/shoes independently within two sessions to
increase independence with self cares. Commented [KW1]: This is great!

LTG#1(.50 pt.)

Problem #2 (.50 pt.)
Client lacks social interaction skills and has difficulty listening to or following
directions as a result of Autism Spectrum Disorder.
Child will be independent in upper and lower extremity dressing to increase independence in
self cares.
STG#2(.50 pt.)
Child will complete a 4-step obstacle course following a picture schedule with minimal verbal
cues within two consecutive therapy sessions to increase direction following while at home.

LTG#2(.50 pt.)

Child will be able to complete 5-6 step obstacle course independently following a picture
schedule to increase direction following while at home and in the community.
Treatment: __/158/8 –
fabulous job
1. Identify The Intervention Approach and the Primary Frame of Reference behind this treatment plan and your rationale for
with this
choosing these. (2 pts) Good job – next time – put Intervention Approach prior to Establish/Restore, and FOR prior to the
section! Keep
others, just so I am sure you know which is which.
doing this for
Establish/Restore-CJ will establish certain performance skills he is lacking. The client will develop skills and abilities that
every
he has not reached yet.
treatment
Developmental-CJ will be able to practice tasks that he should have already mastered according to the typical stages of
plan and you
development. Through working on specific tasks, he will be able to master the certain developmental milestones he is
will have a
lacking.
breeze in the
Sensory Integration- CJ would benefit from sensory integration by helping him with calming effects in order to be able to
program. 
concentrate on tasks and listen to directions. Sensory Integration will improve his behavioral and cognitive skills.

2. Total Treatment Session Time Listed , CPT Code(s) Billed/Minutes/Units. (1 pt.)

30min/2units: 1 unit (22 minutes) 97530 Therapeutic Activity
1 unit (8 minutes) 97535-Self Care

3. List each activity you Plan to complete. (1 pt.) **You need to complete a minimum of 3 different activities (usually you
have an opening, middle, and closing); and you need to plan for the appropriate amount of time for each activity
depending on patient and setting.
Therapeutic Activity: (First ten minutes)-Obstacle Course: Client will do a 4-step obstacle course while following a picture
schedule list to see what to do next. When Cane is doing the swing, ball pit, or squish box, on the obstacle course, those
will calm him down which will help with his behavioral, attention and listening skills.
Therapeutic Activity: (Middle twelve minutes) Therapeutic Listening/Play Chutes and Ladders: Client will listen to music
and play chutes and ladders with COTA and OTAS to improve his cognitive, attention and listening skills
Self-Care: (Last eight minutes)-Dressing: CJ will practice his skills in dressing by doff shirt and donn socks/shoes
a. Relevance and Importance to the client: Describe the activities chosen and how they are relevant and important to
the client. Make sure they are Client Centered (1 pt.)
Obstacle Course: Client enjoys doing obstacle courses and this will calm him down in order to higher his level of
concentration. When completing the obstacle course CJ will use a picture schedule to practice his goal of following
directions.
Therapeutic Listening/Play Chutes and Ladders: Client enjoys playing games. CJ will listen to music which will
improve his attention levels on the task and play a board gam e which will improve his social interaction skills.
Dressing: Client wants to ultimately reach his goals of becoming independent in dressing. He will progress to the
next developmental stages of the dressing process by working on this treatment plan .
b. Objects used and their properties: Describe all of the objects used and their properties for each activity (1 pt.)
Picture schedule: laminated piece of cardsto ck paper with Velcro to place little picture cards on
 Ball Pit-Mats attached to form circle and plastic balls inside the circle
Swings-Medal post with hooks to attach swings on. There are seat swings, bucket swings, or cloth swings
Squish Box-box with foam steam rollers that lift up so child can go in the middle and roll through them
Skateboard Ramp-a wide wooden platform with wheels and wooden ramp
CD player-a black round machine to listen to music
Headphones-Piece to put on head and over ears to hear music, comes with cords to attach to cd player
Therapeutic Listening Tapes-CDs that have music on them to listen too
Chutes and Ladder board game-comes with board and pieces to put on board and move around spaces, a spinner
and instruction manual
CJ’s shirt, socks and shoes-The client’s own shirt (long or short sleeved), socks and shoes
c. Space Demands: Describe the space needed for each activity (1 pt.)
Obstacle Course: Large room, enough space to play/run and hold swings, ball pit, squish pad and mini ramp Commented [KW2]: What is enough space – can you
describe this more, put measurements?
Therapeutic Listening/Play Chutes and Ladders: Open space, enough space to move, table and chairs
Dressing: open space, no obstacles, enough space to move

d. Social Demands: Describe the social demands needed for each activity (1 pt.) Excellent job denoting the social
demands required of each activity!
Obstacle Course: Communicating what the next step in the course is, communicating if wanting to stop or continue
a step and feelings of difficul ty completing task
Therapeutic Listening/Play Chutes and Ladders: Communicating if music is too loud or quiet, playing game with
COTA and OTAS, communicating with COTA and OTAS about game
Dressing: Communicating about feelings of difficulty while dressin g, communicating about the progression of steps
while doffing shirt and donning socks/shoes
e. Sequencing and Timing: List the Sequencing for the entire treatment plan including all activities and the amount of
time needed for each step (1 pt.)
1. Show client the picture schedule-1 min
2. Have client go to first step in the obstacle course after looking at the schedule-.5 min
3. Do first step of obstacle course -2 min
4. Have client go to second step in the obstacle course after looking at the schedule-.5 min
5. Do second step of obstacle course -2 min
6. Have client go to third step in the obstacle course after looking at the schedule-.5 min
7. Do third step of obstacle course -2 min
8. Have client go to fourth step in the obstacle course after looking at the schedule-.5 min
9. Do fourth step of obstacle course -2 min
10. Client will sit at table and turn on the therapeutic listening CD-1 min
11. While listening to music client will play Chute and Ladders-10 min
12. Client will doff and donn shirt-3 min
13. Client with doff and donn socks and shoes-5 min

f. Required Actions and Performance Skills

i. List the specific Occupations, Client Factors, Performance Skills, and Performance Patterns you are
addressing and how the activities are working on these items. (These must be listed in the Purpose section)
(4 pts.)
Occupations: ADLs-Dressing-When client works on dressing he is working on becoming independent in self -
care.
Play-Playing in the gym and with board game client with work on his play skills
Social Participation-When playing the board game with COTA and OTAS client will work on his social
interacting skills
Client Factors:
Attention-All 3 activities require client’s attention to complete tasks .
Emotion-Client works on emotional regulation by doing the obstacle course and calming down; he also
calms down while listening to music. While playing the board game client works on emotions regulation by
not getting mad when losing, listening to and following directions.
Performance Skills:
Attends-All three activities help client strive toward his goal of independently completing tasks without
stopping or interrupting the tasks progression
Initiates-All three activities allow client to practice initiating the next step of each task
Sequences-The obstacle course h elps the client practicing completing tasks in a sequence of events
Expresses emotion-All three tasks help client express his emotions in a way that is socially appropriate.
Client can practice independently regulating his emotions.
Performance Patterns:
Role-Student role: During the therapy session client can practice keeping his concentration on each task,
interacting with COTA and OTAS, and following directions.
Role-Son: Client can work on his goal of following directions at home by following directions during session.
ii. List any Context and Environmental Factors that are being worked on through the activities. (1 pt.)
Cultural-During the therapy session client can work on displaying appropriate behavioral standards and
following directions well. Also, these activities will help with his emotional regulation.
Physical- During the therapy session things are changing and there are transitions between tasks, so client
can practice adapting to change and working on h is goals of following directions.
iii. List the Type of Intervention this activity is. (1 pt.)
 Occupation based- Client prioritizes play. Through doing play activities client is working towards his goals
through meaning and purposeful activities. Dressing allows the client to complete an ADL and become
independent in this area of occupation .

Total Points: All above must be present and appropriate, written professionally, minimal to no grammar/writing errors.

Additional Treatment Ideas: (Make a brief list (4 or more) of all other treatment ideas you would use when working with this individual, provide a brief _2_/2 pts.
description of activity and why you would use it/what it would work on.
Group therapy sessions- Sessions with kids his age to promote social interaction. They could play games with each other to practice displaying appropriate
behaviors and social interaction between each other.
What are you feeling? Game- A game that makes you figure out how certain people are feeling in the game. This would work on emotional regulation and
helping improve cognitive levels.
Racing cars down ramp- The client enjoys playing with cars so racing cars would be a meaningful activity. This activity can help him practice displaying
appropriate behaviors, for example, when losing the race or when interacting with people.
Scooting Pegs- The client will lay prone on scooter board and apply pressure to muscles in order to help him calm down. Client seeks out the
vestibular input this will give that to him.
Culturally Relevant: Provide your rationale for how this treatment plan is culturally relevant (1 pt.), reflective of current occupational therapy practice ___/21/1
(.50 pt.), and based on available evidence (.50).
In our culture it is a norm for kids to be in the typical development stage for their age, follow directions and display appropriate behaviors. These
treatments will help the client be more functional in this culture. These activities are purposeful and meaningful and will help CJ in the areas of
occupations he needs help in.

Evidence Based Practice: ___/31/1

Provide the APA Citation (.50 pt.) for 1 EBP article that you feel provides an appropriate treatment method/Activity for this diagnosis, describe the
Excellent job
treatment method and why you chose it (1 pt.) and how you used it in your treatment (.50 pt.).
Review this Article with your Fieldwork Supervisor and describe how the discussion went? (1 pt.) with this
LaGasse, A. B. (2014). Effects of a music therapy group intervention on enhancing social skills in children with autism. Journal of Music Therapy, 51(3), article and
250-75. Retrieved from http://nctproxy.mnpals.net/login?url=https://search-proquest-com.nctproxy.mnpals.net/docview/1627710689?accountid=40780 utilizing it in
The purpose of this article was to find out the effectiveness of music therapy on children diagnosed with Autism Spectrum Disorder (ASD). The the session.
researchers wanted to know if music therapy in group sessions with children diagnosed with ASD would improve their eye gaze, joint attention and
communication skills. There were seventeen children ages 6 to 9 participating in this study. The children were randomly placed into a music group
therapy session (n=9) and a social skills group (n=8). The two groups met for 5 weeks, twice per week for 50 minutes. The two groups both worked on
social skills and the music group got an extra music therapy session. The group sessions consisted of a welcome activity, sensory activities, social skills
practice and then an ending activity. The music group received extra therapy (music therapy) after the sensory activity. The results show that music
therapy in group sessions that promote social interaction improves eye gaze, joint attention and communication skills of kids diagnosed with ASD. I chose
this method, because the results show that music therapy is beneficial for kids diagnosed with Autism. It improves their attention and communication
skills. I think it will help CJ with his treatment and goals of following directions, better behavioral and cognitive skills. I will use it by having CJ listen to
Therapeutic Listening music and playing a board game with him. The music will allow him to stay calm which will improve his concentration to complete
the task or no or low number of distractions. The OTA thought it was a great idea. She talked to me about Therapeutic Listening program and showed me
how it works. She told me it is beneficial and allows some kids to be able to successfully concentrate on an activity.

Health Professionals: __/2.5/1

Identify the Health Professionals that would be important to collaborate with in regards to this patient (more than 2) (.50 pts.) and discuss why (.50 pts).
Identify when you would refer to these health professionals for consultation and intervention and the process you would follow. (1 pt.) be sure you answer Formatted: Highlight
this last part.

Speech Pathologist- This type of therapy can be beneficial to improving social interaction skills, how to communicate and behavioral skills

Behavioral Therapist- This type of therapy can implement ways to function better and not have as many behavioral difficulties. They will help the client with their
difficulties in displaying not appropriate behaviors in certain situations, for example being not listening or following directions.

Physician-CJ will need regular check-ups and to check on the progress he has made
Further Evaluation __/21/1 – v.
Identify when you would recommend to the OT the need for additional evaluation (1 pt.) and describe why (1 pt.)
good!
The OT will assess him every 6 months to see his progress and if there is a need for more therapy. I would recommend an additional evaluation if the
client has met all the goals or if the client isn’t meeting the goals; because then the OT can make more goals or adapt them so he can succeed.

Community Resources: __1/1/2 –

Identify any community resources that would be valuable to this client (1 pt.) and describe why (1 pt.)
great ideas!
Support Groups- Support groups can help by allowing the child and the family to communicate with other families that have children with autism,
developmental delays and/or anxiety.
Playgroups- Play groups can be beneficial in a way that they are promoting social interaction between the client and other kids. The client can work on his
play skills.
Adaptive Equipment Stores with sensory equipment- Adaptive equipment, for example, swings would be great for the client in order to help him calm
down and get the stimulation he needs in order to be fully functional.

Outcomes: Refer to Table 9: Outcomes on page 34 and 35 in the OTPF. Identify the primary outcomes (minimum of 2) your client will have achieved as __/21/1
the result of the therapy you are providing. Describe how they will have meet these outcomes and why you choose these outcomes.
Occupational performance – they will meet this outcome by working on the areas of occupation of ADL – dressing and play. I chose this outcome because
the goals are for him to become as fully functional as he can be in his occupations and improve his performance skills.
Quality of life – The client will meet this outcome by working on behaviors, social interactions and cognitive skills. I chose this outcome because is about
reaching the clients goals and improving these three things will support CJ’s quality-of-life.
Participation – Client will meet these outcomes by working on the ADL of dressing and play. I chose this outcome because, by working on these two
occupations he will be able to participate more in social groups and hopefully initiate play more.
Total Points:
__/4029.50/30