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Ethical, Pragmatic, and Conditional Reasoning

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Ethical, Pragmatic, and Conditional Reasoning

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Ethical:

I think for all the kids at TLC, therapy is most definitely worth it!! Something that is hard that I have witnessed at my time here firsthand is the struggled with insurance. There have been multiple cases when insurance either has a cap on OT services for the year or denies for paying for OT services in which my OT submits a personal request outlining in detail the progress the client’s make, but how services need to continue to continue to make progress. What’s interesting about this site, in my opinion, is that the child would also be receiving full time ABA services and some Speech services too if eligible for that too. I have seen when OT gets denied by insurance, the ABAs have been great about asking my OT if there are specific things they could target while waiting for requests to get approved from insurance.

All the clients in OT at the Trellis Center are currently at their recommended session amounts per week unless they have a cap with insurance. In my opinion, I think it would be fair to prioritize the clients who come in weekly less than their clinical recommendation because of insurance. It is also in my opinion to prioritize the clients who are showing to have the biggest gaps in their age group norms for skills.

I think being 100% honest is ALWAYS important in documentation. From the discussions I have had with my OT, clients that have been denied by their insurance don’t even read the documentations to decide. It’s passed off a survey given to parents, and they check yes or no on questions. My OT did submit a paper to a client who recently got denied so I think it would be interesting and beneficial for me to read this to better help my perspective.

Something I really respect is the communication between the OT, SLPs, BCBAs, and RBTs. There seems to be a lot of communication either daily between emails or through meetings once a month. I have also seen them ask questions to each other and everyone being very transparent. I believe that is the key to providing best unified care for mutual clients.

Pragmatic:

Ruffalo was diagnosed at University of Kansas Medical Center, and while I am not sure, I am assuming the doctor referred the Trellis Center to Ruffalo’s parents as many of the referrals come from KU med. Ruffalo’s funding source is BCBS-SC and I believe he gets limitless amounts for OT and his recommended amount of therapy is 3 times per week which he meets. Parents get progress notes from each of Ruffalo’s sessions and get consulted during treatment updates. Parents are also able to observe any sessions, ask questions and resources for home and how to implement things as well for generalization. Parent training is also an option. I am currently doing a “full case load” and am seeing all the clients at the Trellis center. I am not at the point to grow my skills past emerging and into proficient. I have a very supportive supervisor and 3rd year student who give me feedback throughout the day and answer all my questions. I also am expected to run any evaluations and complete progress notes/re-evals. All client sessions are 30 minutes long. I see Ruffalo 3x a week totaling 90 minutes. There are a lot of resources in the room and in a google drive I share with the other fieldwork students and OT that also have a lot of resources.

Conditional:

Ruffalo is going a lot of places! He is such a bright and interactive individual. He constantly participates and that is so encouraging. In just 6 months of OT services, he has learned so much and mastered out most of his previous goals. Right now, we are working on self-care independence and preparing for school. I can see Ruffalo being a great student and having real success in school. He is making great gains with his AAC device and with his trajectory will be able to communicate with great fluidity. As of now, therapy is based on what is important for a 6-year-old. As Ruffalo gets older, therapy options will also shift to what is important for someone his age. Social skills, cooking, driving, and other items may be the focus of OT. While I really do not know what job or occupations Ruffalo partakes in when he is older, I do not want to give him the cookie cutter job or something like a grocery store bagger, but instead my job is to help foster creativity and the skills that are the foundation for more complex learning down the line as he is fully capable and already enjoys challenging himself.

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Scientific reasoning

Ruffalo has been diagnosed with Autism Spectrum Disorder, Global Developmental Delay, Pica, and Mixed Expressive-Receptive Language Disorder.

A serious developmental disorder that impairs the ability to communicate and interact. And also individuals with ASD typically show delay in skills, qualifying them for OT services. The range and severity of symptoms can vary widely. Common symptoms include difficulty with communication, difficulty with social interactions, obsessive interests, and repetitive behaviors.

Early recognition, as well as behavioral, educational, and family therapies may reduce symptoms and support development and learning. The term 'developmental delay' or 'global development delay' is used when a child takes longer to reach certain development milestones than other children their age. This might include learning to walk or talk, movement skills, learning new things and interacting with others socially and emotionally. Pica is an eating disorder in which a person eats things not usually considered food. Ruffalo commonly mouths items like crayons, playdoh, small cubes, etc. Mixed receptive-expressive language disorder (DSM-IV 315.32) is a communication disorder in which both the receptive and expressive areas of communication may be affected in any degree, from mild to severe. Children with this disorder have difficulty understanding words and sentences. Ruffalo utilizes an AAC device to communicate and he does not express functional verbal language.

Ruffalo took the PDMS-2 (Peabody developmental motor scales) a little over six months ago during his initial evaluation for OT services. In this assessment, he scored in the less than 1 percentile and showed skills age equivalent to 12 months in grasping skills and 17 months and visual motor integration. At the time, Ruffalo was 5 years and 1 month. While this assessment is good to measure fine motor skills and next steps, it may not be the best choice since it was functionally not purposefully made for something with ASD.

Diagnostic reasoning

Ruffalo has made great progress in self-care independence and fine motor skills. He has made great gains in cutting with scissors and prewriting lines. Currently, the next step for pre-writing skills are being worked on and show to be a struggle such as tracing shapes in the correct orientation. Writing letters may be a barrier in the future as well reading and other academics. Communicating to others is also a barrier but he is making gains with using his AAC device and that is being generalized in OT and ABA services.

Procedural reasoning

Most of Ruffalo’s goals he targets in OT are based on his results from the PDMS-2 and from parent’s wishes. He just got an updated treatment plan of care during his 6-month progress note and mastered out many of his previous goals. Interventions typically take place at a table and chair that are appropriate for his size, and he uses writing utensils to work on fine motor skills. Different and creative ways are used to target these goals. We apply ABA principles to work on problem behavior if it arises such as whining, crying, Pica, so ignoring the behavior if its intentions are to escape from the task or redirecting. And then, reinforcing the behavior we want to see.

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Client introduction, Narrative, and Interactive Reasoning!

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Client introduction, Narrative, and Interactive Reasoning!

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My client, Ruffalo, is a 5 year old male diagnosed with Autism Spectrum Disorder, Global development Delay, Pica, and Mixed Expressive-Receptive Language Disorder.

Narrative:
Ruffalo is a playful and active child currently receiving speech, occupational therapy, and applied behavioral services at the Trellis Center at Kids TLC.

He lives with his mother, father, and older sister. Parents report there were no complications with pregnancy or delivery and no current medical conditions.

Ruffalo qualifies for occupational therapy services due to meeting the criteria for the treatment diagnoses of Lack of Coordination and Weakness. Upon initial evaluation 6 months ago, parent's report primary goals include:
-fine motor tasks
-dressing
-brushing teeth
-bathing

Ruffalo's diagnoses have impacted his ability to be independent in functional activities. He will be working with occupational therapy to gain independence in fine motor tasks, prewriting skills, play, and self-care. Currently he uses an AAC device to communicate.

Ruffalo receives preferred and highest reinforcers during sessions to reinforce correct responses and learning. Ruffalo enjoys physical affection, playing in the wagon, legos and blocks and frequently participates in these activities during breaks.

Interactive:
Ruffalo is a very expressive and interactive child, despite being unable to communicate with functional language. He is learning and strengthening his usage with his AAC device in speech and is expected to use in other services as well. He is able to request and identify items on his device. He verbally expresses his emotions with laughter, crying, whines and shows facial expressions very frequently. He enjoys interacting with adults and will usually grab hands of adults he enjoys playing with and take them to toys.

When interacting with Ruffalo, it is important to give verbal praise for attending to the task, working hard, and correct responses. It is also important to ignore or not give any attention to responses where he tries to escape from the task or whining and to follow through with the demand. Ruffalo also engages in PICA and commonly mouths/eats small items. Knowing this, it is important to plan sessions where limiting this is possible. For example, working with small beads, playdoh, blocking when he brings a crayon to his mouth are important things to think about before or during the sessions. Sitting next to him or behind with arms around him are most beneficial to provide support if needed and limit distractions around. Having the correct chair and table height are also important for him to set him up for success.

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I am at Kids TLC at the Trellis Center which offers integrative autism services. This means children diagnosed with Autism Spectrum Disorder at this site receive collaborative and multi-disciplinary services from Applied Behavior Analysis, Speech & Language services, as well as Occupational Therapy services.

There is one occupational therapist, Sydney Lillis, and one third year OTS from KUMC who completed her fieldwork here and has returned to do her capstone on approving interdisciplinary communication and strategies. There are around 18 children receiving occupational therapy services at this center.

A typical day for a student at the Trellis Center looks like spending a majority of their day completing daily routines and working with their 1:1 registered behavioral technician, socializing with peers, and spending typically 30 minute sessions in occupational therapy and/or speech pathology if needed. Monthly service related meetings take place between the BCBA, OT, and Speech pathologist for overlapping children they are all treating to hear updates from each other and ways to implement what each is teaching and can add in to their own individualized sessions.