Case 1 Joshua, a 4-year-old boy, was diagnosed with HIV and meningitis at 3 months. He has partial hearing loss as a result of the meningitis and had a seizure at 3 years of age. Currently, he is on HAART. Joshua lives with both parents and two older siblings. He does not attend school, and his mother stays home during the day. Joshua was referred to OT one year ago for behavior problems, hyperactivity, and speech and language delay. Autism is suspected. Testimony of the mother: “ J. is difficult, I do not know how to handle his behavior. He is doing things that I do not like. I am worried how to communicate with him and how to stop him doing something naughty. I am worried about him going to the toilet. He does not give any sign at all of needing to go to the toilet. When playing with friends, he argues with them.” OT assessment: Joshua demonstrates hyperactivity and attention-seeking behavior; his mother cannot cope. She gets very irritated. Motor skills are functional, but postural control and more refined complex motor skills are poor. Ability to focus is meager. He has a scattered attention span and is easily distracted. Task performance is not satisfactory; he has difficulty finishing a task. Initiative is limited; he is very absorbed in his own world and gets angry when disturbed. Problem-solving skills and praxis are poor and not up to age level. Activities of daily living (ADL) are not appropriate for his age: He does not indicate his toilet needs. Communication is difficult. Joshua makes sounds and some gestures to communicate, but no words. Joshua shows frustration surrounding his difficulty communicating his needs, and this adds to his misbehavior. He demonstrates problems interacting with others, cooperating, or taking turns. His behaviour can be destructive when in a bad mood or frustrated. He easily gets into fights with other children, breaks toys, screams and runs away. Mother’s expectations of the OT intervention: “For him to change for the better.” Joshua and his mother attended 10 group sessions. Joshua’s mother participated and received guidance on play, communication, boundaries, and influencing behaviour using a positive confirmation approach. She practiced alternative communication. She and other mothers shared ideas on the importance of play, how a child can utilize energy in a positive way, and how to practice this at home on a daily basis. Evaluation: Improvements included less disruptive behaviour and less shouting. Joshua calmed down, and became more sociable and motivated to participate in the group. Following therapy, Joshua communicates more successfully, using more signs and symbols to express himself. This has reduced his frustration. Joshua’s attention span improved, and he learned to share, take turns, and participate in an activity and plan. Joshua and his mother appreciate that he is able to achieve and accomplish something, self confidence has increased, and he has adapted social behaviour, resulting in reduced conflicts. Testimony of mother after treatments: “His behavior has changed. My expectations of the treatment are fulfilled. I am very happy and appreciate what OT did for him. I have learned that playing together is important for my son, that sharing and a positive approach of my son’s behavior is important. I went to the clinic and saw other mothers with children with similar problems as my son, struggling as I did before. I can see that I am more confident to handle my child than those mothers.”

Case 2 Brian is a 3-year-old boy, diagnosed with HIV by PCR in early infancy, on HAART, with cerebral palsy. He lives with his mother and three siblings; his father is deceased. Brian’s mother is mostly out of the home during the day, and Brian is looked after by a 16-year-old cousin. Brian was referred for OT at 2 years, with motor problems due to spasticity and developmental and speech delay. OT assessment: Brian demonstrated problems in motor skills due to hypertonicity in all extremities. He was not able to roll, sit without support, or bear any weight on his legs. He could not stand or walk. It is difficult for him to make deliberate, voluntary and targeted movements. Not able to hold items in his hands, no fine handgrips, hypersensitive to touch and tactile stimulation, not able to make any sound and not able to be engaged in play. Communication is difficult, due to spasticity. Mother finds it difficult to handle and love her child, being so disabled. OT treatment: Brian was engaged in group therapy for 6 months twice a week, were he was stimulated to play and encouraged to communicate with others at the same time. During play, tone regulation and sensory, tactile stimulation was facilitated. Activities such as supported sitting, trunk control, reaching out, handling of objects, rolling and weight bearing of both lower limbs were integrated in a form of play. Desensitization of the hands using different textures was done during play activities. With the mother present at the intervention, she was taught how to continue with the treatment at home. She was also encouraged to discuss the problems and experiences with other parents, so they could learn from each other and be stimulated in problem solving. Evaluation: Over time, Brian was able to roll, bear weight, sit unsupported, stand independently, and reach out for objects and manipulate them independently. He can engage in play, and he is able to communicate his needs. Sharing with other parents helped his mother to accept her child in a more positive and loving way. She was able to support him constructively without making him too dependent.