Occupational Therapy Evaluation Report

Occupational Therapy Evaluation Report

Christopher DemoDate of Evaluation: 10/10/2013

Date of Birth: 5/4/2006Current age: 7 years, 5 months, 6 days

Occupational Profile

Christopher is in the second grade at Verygood Elementary School. His teacher, Ms. Astute, referred him to occupational therapy because of her concerns with getting work completed. She reported that Christopher is very smart but she fears that his difficulty getting work done will interfere with his performance in school. She reported that he has a very hard time forming letters and numbers for a second grader and does not seem to hold his pencil correctly. She wonders if it is because he is a “lefty.” She said that during a recent cutting activity, Christopher did not hold his scissors correctly and did not cut along the line. She wanted to make sure that Christopher was referred early in the school year for related services so that he received the help he needed throughout second grade.

Christopher’s parents were surprised to learn of his teacher’s concerns. They have not had any prior concerns about Christopher’s development or performance in activities at home. Christopher is their only child and they did not know what to expect of him for writing and craft activities. They reported that Christopher was not interested in these types of activities and they did not push them. They reported that Christopher really liked computer games and since the family got an I-Pad, Christopher has played many games on it, using the touch screen. When his parents work, Christopher goes to his grandma’s house, where he plays outdoors, but does not have many other children to play with during the day. They said he frequently engages in pretend play in the woods behind his grandma’s house. Christopher explained that he builds forts and “goes fishing” in the stream with a fishing pole that he has made. He does not usually go to the park as he does not particularly like the playground equipment there.

Observation of Performance

Christopher was seen in his classroom during an activity that Ms. Astute said was a daily one for the children. Christopher, as well as all the students, were to write a paragraph on the topic of their choice. Christopher chose to write about dinosaurs. Christopher began the activity by kneeling on his chair, instead of sitting in his seat. He initiated opening his notebook, located his pencil on the table and reached to pick it up using his right hand. He lowered himself in in his chair, and demonstrated trunk stability as he kept his back straight and with his head down as he looked at his notepad. He stabilized his paper by kept his right hand on top of the page and held his pencil predominantly in the web of his thumb and index finger, making his tripod grasp appear a little awkward. He initiated writing a few words on his paper, then got up from his chair and walked across the room and asked his teacher to assist him on writing the date on his paper. Christopher went back to his seat to continue the writing exercise and throughout the entire activity, he sat in his seat with his body leaning forward, his elbow flexed and forearms rested on the tabletop as he wrote his paragraph. He continued to hold his pencil with the same grasp and constantly moved his body while in his seat, by changing his body position from rocking backward and forward, as well as looked up around the classroom every few seconds. As he leaned forward in his chair, he pointed his toes and remained with his feet either not completely flat on the ground, or wrapped his legs and feet behind his chair. About 4 minutes into the activity, Christopher positioned himself on the chair so that he was kneeling again on it and leaned forward on his elbows while writing and then transitioned back to a seated position. At one point of the activity Christopher dropped his pencil and was able to bend his trunk and reach with his right arm to grab the object from the ground and place it back on the table without falling from his seat.

Christopher’s final paragraph was about a page long. He was able to sequence his steps in a logical order by writing his words from left to right and top to bottom on his page. He was able to write on the line, and the size of his letters and words were consistent and spaced evenly. He printed phonetically to a certain degree, but some of his letter formations looked a little shaky and scattered on the page. He also mixed up his lowercase and uppercase letters, and was able to read part of his paper out loud to his teacher.

Analysis of Observation:

Christopher demonstrated difficulty in completing his writing exercise by not being able to attend to the task without taking breaks and looking up. He demonstrated awareness of his social environment by acknowledging his teacher when asking question, and showed his ability to express emotions as he responded to her questions and did not appear distracted by other students in class. He was also able to show postural control as he sat upright in his seat, but lacked strong trunk stability due to constantly leaning forward in his chair, changing body positions and not keeping his feet on the ground throughout the activity. He was able to grip his pencil, but demonstrated a lack of fine motor hand manipulation as exhibited by when he fumbled several times with his pencil, and showed a slight hypermobility in the MP joints of his fingers when he waved them in the air. Christopher understood how to do the task, but he seemed to require more time to complete the writing activity than other students. His fine and gross motor skills will be further examined in a standardized assessment to formally determine if his motor skills could be affecting his difficultly in performing tasks at school.

Standardized Assessments Administered

Because of the difficulties noted in the classroom observation, Christopher was given the Bruininks-Oseretsky Test of Motor Proficiency (BOT2). The BOT2 evaluates overall fine motor skills, which Christopher demonstrated difficulty with when drawing and writing. Because gross motor skills provide a foundation for fine motor skills, Christopher’s gross motor abilities were also evaluated using the BOT2.

Results of the Standardized Assessments

Christopher was given the BOT-2 assessment, which used 8 subtests with 4 composite scores to assess Christopher’s fine and gross motor skills. Christopher was assessed on his manual coordination skills through activities such as cutting out a circle and copying a square. For fine manual control, this test revealed that Christopher is below average for his age, performing at the 3rd percentile for his age group, and overall scored 1.9 standard deviations below the mean. His fine motor precision and integration were 1.8 standard deviations below the mean. For his manual coordination skills, his manual dexterity and upper limb coordination were tested by doing activities such as transferring pennies, sorting cards and throwing a ball at a target. For Christopher’s manual coordination skills, he scored well below average range for his age group, performing at the 2nd percentile and over 2 standard deviations below the mean of his age group. To test Christopher’s body coordination, he performed activities such as jumping jacks, walking forward on a straight line and balancing on one leg. For the results of his body coordination, he scored well below average in both bilateral coordination and balance, which he performs both skills in the 1st percentile for his age group, and his score is over 2 standard deviations below the mean. Additionally, Christopher was tested on his strength and agility by doing activities such as running, standing long jump and doing sit-ups. Christopher scored well below average in strength and agility, performing in the 2nd percentile for his age group. His strength and agility score is 1.4 standard deviations below the mean scores for his age group. When executing push ups on hands and knees, Christopher’s score for strength is 2 standard deviations below the mean for his age group

Interpretive Summary and Recommendations

Christopher was referred to occupational therapy by his teacher, who was concerned with his ability to complete schoolwork on time, as well as having difficulty with writing and cutting paper in class. After observing Christopher in class, he exhibits difficultly in body positioning and being able to manipulate objects, such as a pencil, when doing assignments. The results of the BOT-2 assessment concluded that Christopher is below or well below average in all areas of both fine and gross motor skills for his age group. His motor skill deficits will impact his ability to perform as a student, such as being able to do arts and crafts activities, or play outside on the playground equipment, which are all important activities that are age appropriate for Christopher. Occupational therapy is recommended for Christopher to support his performance in school activities.

-______

Lian Todd, 0ts, 10/10/2013

Child’s name ______Christopher______Your name ______Lian Todd______, OTS

Child’s age______7 Years,5 Months______

Practice setting and context of services:

Occupational therapy services 2 days a week for 30-minute sessions at Very Good Elementary school.

Occupational Profile information highlighted to support your intervention plan: Include information about the child as a person and reason for referral & concerns identified by the child, parent, and/or teacher and their identified desires:

Christopher is a second grader at Very Good Elementary School who has been referred to occupational therapy services to improve his functioning at school. Although Christopher is a bright student, his teacher has noticed that he does not complete his schoolwork as fast as the other children and has poor letter and number formation. His teacher would also like him to improve on school-related tasks, such as doing arts and craft projects that require cutting paper. Before Christopher’s referral, his parents were unaware of his difficulties at school. They also explained in the interview that Christopher does not enjoy doing arts and crafts, nor chooses to play on playground equipment with other children, but he does like to play outdoors, build forts and fish. They also stated that he is able to do pretend play by himself. Christopher also enjoys playing games on his iPad and spending time with his Grandma. Due to Chris being their only child, they weren’t sure what activities he’s expected to do at his age level in or out of school, but want him to function as best he can for his age group at home and at school.

Summary of observation and performance analysis that directly support your intervention plan:

Christopher was observed in his classroom participating in a writing assignment with his classmates. Christopher was slower to start the assignment than his other classmates, exhibited by sitting in his seat for several seconds, then got up from his chair and walked across the classroom to ask his teacher what the date was. Once Christopher returned to his seat, throughout the entire activity he was able to keep a straight back, but kept his body leaning forward with his elbows bent and forearms resting on the tabletop as he wrote his paragraph. He stabilized his paper with his right hand on top of the paper, and held his pencil predominantly in the web of his left thumb and index finger, making his tripod grasp appear a little awkward. He constantly moved his body while in his seat by changing his body positions from rocking backward and forward, kneeling on his seat, as well as looked up around the classroom every few seconds. His feet were also either not completely flat on the floor, or he wrapped them behind the back of the legs of his chair. At one point of the activity, Christopher dropped his pencil and was able to bend down sideways to reach it with his right arm to grab the pen fro the floor without falling from his seat. Chris was able to complete the assignment and showed his letters and words were written on the line and were fairly consistent in size and spaced evenly, although some letters did look a little shaky and scattered on the page. He also mixed up his lowercase and uppercase letters and he could read his paragraph out loud to his teacher. He seemed to require more time to complete the writing task than other students.

Christopher was given the BOT-2 assessment, which examined areas of both his fine and gross motor skills. For his assessment of fine manual control, both his fine motor precision and integration are below average for his age, which will make tasks such as cutting paper difficult for him to do. When assessing Christopher’s gross motor skills, he is also well below average for his age group in manual coordination, body coordination and strength and agility, scoring 2 or more standard deviations from the mean scores in his age group. Manual coordination includes manual dexterity and upper-limb coordination and body coordination includes both bilateral coordination and balance. In Manual dexterity is the ability to move our hands with coordination and skill. Bilateral coordination is being able to use both sides of the body at the same time. Chris’s overall weakness in gross motor strength will impact his ability to write and do arts and crafts activities, because he does not have the postural strength or control overall in his body to support his fine motor movements.

Notes for table:

Begin by stating the present performance level and then writing 3 measurable objectives, to be met within one year, in the table below. Choose one of these three objectives, write 2 short term measurable objectives under that annual objective.

Intervention approaches should promote Establishing skill or underlying body function or internalized routine. You will have a total of 6 activities for the child.