Occupational TherapyEvaluation
Child’s Name: Devivo, Nathan Date: 2-27-07
Date of Birth: 8-7-06 Age: 7 months
Address: 17914 Vista Ct., Canyon Country CA 91350Phone: (818) 482-7562
Caregiver Name: Marcela Devivo & Owen Andrew Language: English
Diagnosis: Holoprosencephaly
Background Information: Nathan was referred for services through Progressive Steps due to his diagnosis of holoprosencephaly. He currently receives twice weekly physical therapy, once weekly child developmental therapy, and has been receiving once weekly occupational therapy, but will be increasing to twice weekly in the coming week. All therapies are provided in-home with mom, dad, or full-time caretaker present.
Nathan was born at full-term gestation via c-section. Although her pregnancy was without complication, a routine ultrasound performed at 36 weeks showed some abnormalities and a diagnosis of holoprosencephaly was suspected. An ultrasound after an uncomplicated birth confirmed the diagnosis of holoprosencephaly. Since birth, Nathan has had an echocardiogram and swallowing test, both of which were within normal limits. Nathan has had shunt surgeries at three different times, including two in November, 2006 and one in January, 2007 to replace an existing shunt due to infection. Nathan is currently not taking any medications.
Nathan lives with his parents. A full-time caretaker helps with Nathan at the home.
This evaluation was conducted in the home with the caretaker in the room. Nathan was cooperative and the results are considered valid and reliable.
Neurological Status: Muscle tone is increased throughout. Joint range of motion is passively within functional limits, though some active range in upper extremities is limited due to increased tone. At rest, Nathan demonstrates open hands, which fist during excitement or activity. Extensor patterns are noted in back, and lower extremities. Formal hearing tests have been done and results were within functional limits. Three ophthalmologyappointments have resulted in a diagnosis of cortical visual impairment.
Assessment Tools Used: Hawaii Early Learning Profile (HELP) Strands, Developmental Assessment of Young Children (DAYC),caregiver interview, and clinical observations.
Findings:
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DAYC
Subtest / Raw Score / Standard Score / Age Equivalent / RatingAdaptive (Self-Help) / 3 / 70 / 1 month / Boarderline
HELP Strands
Fine Motor Skills: / 3-4 months1 of 2
Occupational Therapy Evaluation
Child: Devivo, Nathan
Evaluation Date: 2/07
Fine Motor Skills: Nathan demonstrates grasp and prehension (the way things are held) delays. He uses an ulnar palmar grasp to hold things and is able to follow an object using his eyes, without head movement. He is beginning to inspect his hands and activates his arms at the sight of a desired object, though he cannot accurately reach to a toy due to increased tone. Nathan is able to hold small toys, when handed to him but is not yet able to transfer from hand to hand. Nathan demonstrates decreased strength in his neck, however, when placed in midline, he is able to hold his head and look at an object held above him. He does not yet clasp his hands.
Self-Help Skills: Nathan enjoys his bath and expresses displeasure when clothing is pulled over his head. He opens his mouth in anticipation of feeding. Nathan receives his nourishment through bottle feeding and is given small amounts of cereal, baby food, and soft, cut up table foods. Nathan takes about two naps during the day (2 hours) and after an initial nightly sleep of 4-6 hours, is up about every 2-3 hours for a bottle or to play.
Sensory Processing: Nathan demonstrates decreased proprioceptive processing in his hands and arms. His regulation appears to have improved since shunt placement, as he is better able to calm himself. Continued monitoring for sensory processing dysfunction is necessary as Nathan becomes more active in and aware of his environment.
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Occupational Therapy Evaluation
Child: Devivo, Nathan
Testing Date: 2/07
Recommendations:
~Continued twice weekly occupational therapy to increase fine motor ability, and monitor feeding and sensory processing issues.
Occupational Therapy Goals
Target Date: 8/07
1. Nathan will reach for and grasp a toy, while in the prone position in 3 out of 5 opportunities.
2. Nathan will drop an object, voluntarily, to retrieve another object, in 2 out of 4 opportunities.
3. Nathan will bang two blocks together, with one in each hand, in 3 out of 4 opportunities.
4. Nathan will bring a cracker to his mouth in 1 out of 3 opportunities.
5. Nathan will pick up a pellet-sized object, using a raking grasp, in 1 out of 3 opportunities.
6. Nathan will participate in a home program to improve fine motor and sensory integration skills 7 days per week.
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Jacqueline Miller, MA, OTR/L
Occupational Therapist
CBOT#9083 NBCOT#220178
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