CASE

STUDY
Angel Alvarez
 CLIENT INFORMATION
Gender: Male
Age: 4
Level of education: Preschool

Primary Diagnosis: Autism Spectrum Disorder & Sensory Processing Difficulty

Notes: The client is a 4-year-old male with a
Medical History: N/A
new diagnosis of Autism Spectrum Disorder
(ASD). He has a history of speech delay,
Ethnicity: Latino or Hispanic
sensory processing difficulty, and severe
obesity. His primary mode of communication
is non-verbal, often guiding his mother by the
hand to express his needs or interests.
 Client
Information
SUPPORTS
Lives with his mother and grandparents
Has a dog named Sunny
Access to early intervention

INTERESTS
bubbles
zoo animals
underwater animals
puzzles, though he has a hard time putting
them together.
prefers chewy foods
does not like hard foods
 CLIENT FACTORS

Values/Beliefs/Spirituality: Body Structure:

Snacks and juice Strength: Musculoskeletal System

Body Functions:
Strength: Body awareness
Barriers: Childhood
obesity
PERFORMANCE
SKILLS
The client has difficulties in social interaction,
communication, and sensory processing. He
continues to only use single words but has
added “Banana and carro” to his vocabulary He
can get nervous in certain environments with
lots of people/kids around.
PERFOMANCE
PATTERNS
The client’s daily routine may be
characterized by repetitive behaviors, limited
verbal communication, and tantrums,
especially when tired. He tends to wander
away and tries to open doors. He does not
initiate interactions with others and generally
has little interest in playing with others.
 PROFESSIONAL
COMMUNICATION
Regular communication with the client’s mother and
other professionals involved in his care will be necessary
to monitor his progress and adjust the intervention plan
as needed.
Participation and
compliance
The client’s participation in the
intervention activities and his mother’s
compliance with the recommendations
will be key factors in achieving the
family’s goals.
 Context & Environment
Personal:
Strength: Supportive mother and
grandparents that are involved in
his care.
Barrier: He has a difficult time
expressing himself.
Environment:
Strength: supportive family
Barrier: None Identified
Cultural Context: The child comes from
a bilingual family that values education
and independence.
Personal Context: The child is in the
early years of elementary school and is
learning to adapt to the structured
envirnment.

He is exposed to both English and

Spanish at home but seems to
understand more English.
 Intervention
Observed
Pecs board
During snack time, the child utilized a
Picture Exchange Communication Board
(PECS) board to express his snack
preference for the CBT. The board had
many snack options such as Cheetos,
Oreos, Goldfish, and more. Once he chose
his snack, he would go to the board grab
the picture, and hand it to the CBT and the
CBT would hand him the snack.
The type of intervention: Preparatory
mehtod
 COLLABORATION
Collaboration with the client’s mother, as well as other
professionals involved in his care (such as speech
therapist, dietitian, and pediatricians), has been the
reason for the success of the intervention plan
 HEALTH
PROMOTION
Levels of prevention: Tertiary
OT’s Role in Health Promotion/Prevention
Increase sensory processing differences,
including gagging and picky eating.
Promote performance in the classroom
Expected outcome of OT:
Promote a diverse diet
Increase attention span and emotional
regulation
Discharge Environment: Preschool
 Reference
American Occupational Therapy Association. (2020).
Occupational therapy practice framework: Domain and
process (4th ed.). American Journal of Occupational
Therapy, 74(Suppl. 2), Article 7412410010.
https://doi.org/10.5014/ajot.2020.74S2001