Occupational Therapy Evaluation

OCCUPATIONAL THERAPY EVALUATION

NAME: Gregory Reynolds DATE: 10/19/2006

DOB: 6/26/2001 THERAPIST: E. Leonard

AGE: 5 years 4 months TEACHERS: R. Rueben, J. Milton, N. Bell

BACKGROUND INFORMATION:

Gregory Reynolds is a delightful, fun little boy, aged 5 years 4 months. He lives with his parents and older brother, Marvin, in Sometown, North Carolina. Gregory particularly likes books and toys related to themes such as robots, superheroes, and his current favorite, The Wizard of Oz. He and his family engage in many activities together, and he enjoys these as well. Gregory was diagnosed at around 30 months with a variant of Landau-Kleffner syndrome (LKS), or acquired epileptic aphasia. He has been treated since that time with corticosteroid medication (Prednisone), and has received physical therapy, occupational therapy and speech/language therapy. From late January 2005 to the present, Gregory has attended Child’s Play Child Care Program, which is an inclusive program; he receives occupational and speech therapy, and special education services in his preschool classroom setting, and also privately. This evaluation was conducted in preparation for a consultation with a specialist in the treatment of LKS, and for intervention planning.

ASSESSMENT METHODS:

Records review and informal interviews with Gregory’s mother and classroom teachers

Direct observation of and participation with Gregory in classroom activities

Standardized methods:

·  Adapted administration of the Fine Motor portion of the Peabody Developmental Motor Scales-2

·  Motor-Free Visual Perception Test – Revised (MVPT-R)

·  Sensory Profile

CONCERNS/PRIORITIES

The following areas are those identified by Gregory’s parents and/or classroom teachers during the most recent interdisciplinary IEP planning meeting, in late April, 2006:

·  Communication: conversational skills, clarity of speech, response to questions/comments

·  Social participation: Initiating and maintaining peer interactions

·  Self-care routines: brushing teeth, eating greater variety of foods

·  Play skills:

o  participation in outdoor play,

o  expanding manipulative, constructive and pretend play (including drawing pictures, more complex building/assembly and more complexity and variety in pretend play)

o  increasing length of engagement (playing for a longer time in those activities) with greater independence from adult support

o  increasing play with peers

Recently (in the last 2 months), additional concerns have been raised about general sequencing and organizational abilities, including motor planning.

ASSESSMENT OF OCCUPATIONAL PERFORMANCE ISSUES

Occupational Performance Areas:

Activities of Daily Living: Gregory can do basic dressing tasks on his own most of the time, and is independent in toileting. He participates well in mealtime routines at home and school, overall, but is a “picky eater,” with four or five preferences (chicken nuggets, pizza, grits, cheese, grilled cheese

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sandwiches). He completes basic grooming and hygiene tasks with age-appropriate adult assistance, with the exception of his resistance to brushing his teeth.

Preschool participation and play: Gregory understands classroom routines and generally participates well in the overall “flow” of classroom activity. His ability to engage in these overall classroom routines is best supported by a combination of verbal and visual/environmental cues, and he sometimes needs adult support to register or attend to those cues. During structured play and learning activities, Gregory participates actively and uses toys and materials that his peers are using. He uses verbal directions and adult and peer models to help him know what to do in these more structured situations. However, during free play or unstructured play times in the classroom and on the playground, he tends to engage for short periods of time, and his use of toys and materials is fairly simple (e.g., sand or sensory play, repeated rather than expanded episodes of pretend play on the same general theme, simple building activities). Gregory is inconsistent in his interest and ability in typical drawing/art activities. At times he can use demonstrated models and verbal cues to draw pictures of things that are recognizable, but these are typically related to topics that have great significance for him (superheros, etc.). In this context he can use some variety of shapes in his drawing, though angles and changes in direction tend to be “rounded”, and he cannot, for example, just “draw a square.” Gregory often uses an immature grasping pattern on writing tools, but when given shorter tools or reminders, he uses a more controlled grasp and has more “precision” in his drawing. He can cut across a sheet of paper, and cut paper into pieces, but has some difficulty cutting on a line to cut things out.

Social Participation: Gregory interacts readily with adults and is typically very friendly, especially when familiar adults are also present. He has preferred topics of conversation, and his ability to deviate from these varies a great deal, in part due to effects of his diagnostic issues and the medication he takes to mediate those effects. Frequency and duration of peer interactions vary in unstructured play situations, but tend to be notably less than in situations structured by adults, and he interacts more easily with one or two children around a topic of his choosing than in more spontaneous or complex social play situations.

Results of Standardized Testing

Peabody Developmental Motor Scales – 2 (PDMS-2):

The PDMS– 2 is a standardized assessment of motor skills for children ages 0-7 years. Only the fine motor portion (2 subtests, grasping and visual-motor integration) was administered to Gregory. Because the tasks in this assessment are de-contextualized, decreasing their meaning to children, the examiner modified administration to group items in such a way that an end-product or purpose was more evident. For example, the items related to folding paper and copying shapes are combined into a "making a little book" activity. The verbal directions given for the actual test items are the same as those provided in the administration manual, so scores derived from this administration are considered valid.

Gregory’s scores are as follows:

Subtest / Raw
score / Age equivalent / %ile Rank / Standard score
(x = 10, SD = 2)) / TOTAL FINE MOTOR QUOTIENT
(x=100, SD = 15)
Grasping / 45 / 37 months / 2 / 4
Visual-Motor Integration / 128 / 48 months / 16 / 7
73 (3rd %ile)

As noted under “Preschool participation and play” above, using mature grasp of writing tools, copying shapes and cutting on a line were difficult for Gregory, though he made a sincere effort to complete all tasks as directed. He needed verbal and gestural directions repeated three times before he connected

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two dots with a straight, 6” line, and though he has been observed to color in shapes with greater accuracy, on that item in this test, he crossed lines numerous times. He was able to replicate block designs with 3-5 blocks, and was able to approximate the 6-block designs.

Sensory Profile:

This tool is a standardized criterion-referenced 125-item questionnaire, which is completed by a parent or other caregiver, and offers a comparison of scores, across 13 sections, with those of typically developing children. Ranges of scores include typical, probable difference (in sensory processing), and definite difference. As with any assessment of sensory processing, it is important to look at overall performance trends, and relative strengths and weaknesses, rather than assigning significant value to any one item or section. In Gregory’s case, the results must be interpreted carefully due to the potential relationship of diagnostic issues to his patterns of sensory processing, placing emphasis on general patterns of reaction to sensory input in the environment, and modifications that may be necessary to support his overall performance in a variety of activities. Though there was no specific research found about Landau-Kleffner and sensory integrative dysfunction, there is evidence that epilepsy and other specific seizure disorders can be associated with a variety of sensorimotor, sensory processing and perceptual difficulties, and difficulty processing auditory information is well-supported in the literature related to seizure disorders.

In the chart below, raw scores are listed as a ratio of Gregory's score over the number of possible points for items in that section, with higher scores indicating higher levels of functioning in terms of sensory processing. The scores listed as a ratio (on right side of the “Raw Score” column) indicate Gregory’s responses when on a 15 mg dose of prednisone; the raw score in blue (to the left side of the column) reflects his responses when on a 1.5 mg dose (only reported here in sections in which raw scores differed from responses when on 15 mg dose).

SECTION / RAW SCORE / RANGE
Typical / Probable
Difference / Definite
Difference
Sensory Processing
Auditory Processing / 18 / 23/40 / xx
Visual Processing / 29/45 / x
Vestibular Processing / 48 / 50/55 / xx
Touch Processing / 65/90 / x
Multisensory Processing / 25 / 29/35 / x / x
Oral Sensory Processing / 37/60 / x
Modulation
Sensory Processing Related to Endurance/Tone / 21 / 29/45 / xx
Modulation Related to Body Position and Movement / 35 / 39/50 / x / x
Modulation of Movement Affecting Activity Level / 21 / 23/35 / x / x
Modulation of Sensory Input Affecting Emotional Responses / 17/20 / x
Modulation of Visual Input Affecting Emotional Responses and Activity Level / 18/20 / x
Behavior and Emotional Responses
Emotional/Social Responses / 65 / 67/85 / xx
Behavioral Outcomes of Sensory Processing / 16 / 17/30 / xx
Items Indicating Thresholds for Response / 13/15 / x

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FACTOR / RAW SCORE / RANGE
Typical / Probable
Difference / Definite
Difference
Sensory Seeking / 65 / 70/85 / xx
Emotionally Reactive / 59 / 61/80 / xx
Low endurance/Tone / 21 / 29/45 / xx
Oral Sensory Sensitivity / 29/45 / x
Inattention/Distractibility / 18 / 24/35 / x / x
Poor Registration / 39/40 / x
Sensory Sensitivity / 12 / 14/20 / x / x
Sedentary / 8/20 / x
Fine Motor/Perceptual** / 5 / 6/15 / xx

These results indicate overall that Gregory has mild-moderate difficulty processing sensory information, particularly auditory sensation and sensation in his mouth. He has mild sensitivities to touch and may find visual information distracting or disorienting if not shown how to use or interpret it. While he presents with low endurance and muscle tone, and tends often to prefer more sedentary activities, it’s difficult to determine to what extent this is related to sensory processing (largely vestibular and proprioceptive systems), as vestibular processing, poor registration factor, and most of the activity level sections are in the typical range. It’s possible that steroid medications, or effects of seizure activity itself, are also influencing endurance, energy and tone. On lower doses of medication, Gregory responds to his environment with greater distractibility, is somewhat more sensitive to sensory input in general, and demonstrates significantly greater difficulty with modulating input related to energy level, tone and movement required for a variety of activities.

Motor-Free Visual Perception Test - Revised: This is a standardized test of overall visual-perception, comprised of 40 items which represent the following types of visual perceptual skills: spatial relationships, visual discrimination, figure-ground, visual closure and visual memory. Raw scores are converted to a Perceptual Quotient, which is based on a mean of 100 and standard deviation of 15 (average range is 85-115), and a Perceptual Age. Results for Gregory are as follows:

Raw Score = 18

Perceptual Quotient = 89

Perceptual Age = 4 years 9 months

This test is intended to provide only a general assessment of visual perception, and the authors caution against attempting to identify deficits or strengths in specific sub-areas based on test performance. However, during administration it was interesting to note the ease with which Gregory correctly identified answers on the items related to visual closure, which is the ability to identify figures when only parts are presented (30-50% of children his age in the normative sample did not answer correctly for the items he got right). He had the most difficulty with spatial relationships items, though they are the last test plates, and waning attention may have been a factor. Overall, Gregory’s scores fall in the lower end of the average range on this test of visual-perceptual skills.

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SUMMARY

Gregory Reynolds is an engaging 5 year 4 month old boy diagnosed with a variant of Landau-Kleffner syndrome. He engages easily with adults, completes most self-care tasks with age-appropriate independence, responds well to multisensory approaches to teaching, and has (low) average visual-perceptual abilities (on testing). He also has an active and supportive family, and a number of supportive resources that include his preschool setting and private therapists. Results of this evaluation indicate difficulties in the following areas of occupation:

o  Outdoor play

§  energy and endurance

·  sensory processing (esp. proprioceptive)

·  ? effects of medication/diagnosis-related problems

§  social interactions with peers

·  language

·  persistence (continuing to pursue interactions with peers)

·  flexibility (varying themes, responding to spontaneous changes in play, etc.)

o  Constructive play

§  tool use, including manipulation of writing tools and scissors

·  sensory processing (esp. tactile, proprioceptive)

·  fine motor/motor control

·  postural control (muscle tone, endurance)

§  planning, sequencing and execution of drawing/writing and cutting tasks

·  sensory processing (esp. visual, tactile, proprioceptive)

·  motor control (for execution)

·  cognitive sequencing abilities

§  consistent ability to use visual information to copy 2- or 3-dimensional forms

·  visual sensory processing

·  attention to task

o  Pretend play

§  social interactions and language

§  flexibility and spontaneity in themes of play

o  Self-care (brushing teeth, eating variety of foods)

§  oral sensory processing

A number of factors affect Gregory’s occupational performance, including medical issues related to his diagnosis and medication, Gregory’s intrinsic capacities for sensory processing and in fine-motor and visual-motor skill areas, and his ability to use language. Because these factors interact with one another, and the supports and barriers within Gregory’s environments must also be considered, continuing to use an interdisciplinary approach to intervention planning seems best. This approach has been facilitated significantly by Gregory’s mother, and continued close collaboration of all service providers (physicians, teachers, therapists, etc.) is recommended.

______

Elsa Leonard, M.S., OTR/L

Occupational Therapist