Introduction and Occupational History
The client is a ten-year-old student whose name has not been disclosed for privacy reasons. The client has been referred for school-based occupational therapy evaluation because of her unpredictable behaviour in class. The student has poor and illegible handwriting and has increasing behavioural outbursts in class. She says her work “is not as perfect” as others. She wants to have her work hung on the classroom exhibit announcement board and “clip up to fantastic.” Her main accomplishment right now is to accomplish a higher level in the classroom behaviour management system and have her work hung on the excellent board. Class teacher reports that the student’s handwriting is illegible and that she is having emotional outbursts at an increasing frequency. The student is currently receiving special education services for speech and language impedance. The client lives with her parents and an elder brother in a lovely big house. She is mostly provided for by her nanny who has been like a mother to her because of her mothers busy work life. Brother, whom she spends most of her time with says she started to be agitated and irritated all the time when her nanny, Stella (not real name) decided to leave the family to further her education. She loved Stella because she has always been there for her when mom and dad travel for weeks to conduct business, says her brother. Some of the occupational successes the client has had include; finishing homework, finishing house chores, plays with dolls, social participation with her older brother (16 years old). She likes dancing and playing princess. Some of the significant occupational successes include one-on-one cooperation through life skills program at school and thriving behavioural supports for home and community outings.
According to Berk, Laura E. (2012), developmental milestones of the client according to the five main grouping categories is as follows:
Developmental milestone category
Finding
Physical growth and development
The client lost two teeth this year.
As compared to last years weight and height, she gained 2.5kg and grow about 5cm, respectively.
Cognitive development
She knows the complete date.
She knows days of the week and months of the year.
She is excellent at math.
She cannot write simple stories because of her illegible handwriting.
Emotional and social development
Unlike other kids, the client does enjoy playing alone.
Sometimes show irritation to her parents.
Language development
She likes reading but not writing.
She almost speaks like an adult.
Sensory and motor development
She likes riding her bike.
Occupational Profile
(This occupational profile was created according to AOTA occupational therapy profile)
The information is acquired from the client’s point of view through both formal meeting strategies and informal discussion and prompts an individualized, customer focused way to deal with mediation (American Occupational Therapy Association, 2014).
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