Occupational Therapy Evaluation Report

Clients Name: Marcus Low Date of Evaluation:

September 10, 2005
D.O.B.: March 17, 2001 Age: 4 years 5 months
Diagnosis: Autism Spectrum Disorder Physician: Dr.
Blanchard
Parents Names: Diane Low and Abbie Springer
Address: 135 Tree Street Cheshire, CT 06410
Phone: 821-555-8127 Email:
[email protected]

Occupational therapy is a family-centered service that enables

engagement in activities and social participation. Occupations
are the meaningful things you do on a regular basis. A childs
primary occupations are playing, learning, and gaining
independence in self-care.

Intervention in occupational therapy can include the process of

occupation (the DOING of something meaningful), as well as
adapting the environment or altering the task demands to allow
for occupation to occur. Intervention can be provided directly
with the child, or via consultation with significant persons in the
childs life.

The typical OT evaluation consists of record review, interviews of

family members, important adults in the childs life, and the child
him or herself when appropriate or feasible. Additionally, the
occupational therapist will observe the child at work and play,
and use specific tests or assessment tools as appropriate.

This report will provide you with a summary of the occupational

therapy evaluation that was completed for your child.
REASON FOR REFERRAL:
Marcus has been referred for an occupational therapy evaluation
by his teacher, who is concerned about his behaviors in the
classroom.

BIRTH AND MEDICAL HISTORY:

Marcus was born full term without complications. His mother
reported observations of lack of eye contact within his first year,
and began receiving birth to three services. His interest in
sensorimotor play (play that focuses on using senses and
movement, such as putting a toy in his mouth to chew) continued
beyond developmentally appropriate. Marcus also demonstrated
a repetitive behavior of lining up his toys. At the age of 3, Marcus
was diagnosed with Autism Spectrum Disorder.
Marcus is the son of Abbie and Diane, and has no siblings. His
biological father is unknown, and the medical history is
unavailable. Marcus has no significant health concerns.

EVAULUATION METHODS:
Sensory Profile: This tool measures the childs sensory
processing. Sensory processing is the ability of the mind to make
sense of the information collected by the bodys senses (e.g. what
they see, hear, taste, smell, and touch). This information is useful
because sensory processing affects functional performance, or
the ability of the child to complete necessary activities.
The HELP: The Hawaii Early Learning Profile provides the
occupational therapist with lists of incremental developmental
milestones. These lists are used to establish measurement of
current abilities and track future gains. The therapist can also
use this tool to decide what skill should be focused on next
during therapy.
*Reference was also made to the Vineland Adaptive Behavior
Scales and Parenting Stress Index completed by the school
psychologist, the Childhood Autism Rating Scale completed by
the physician, and the Motivation Assessment Scale completed
by the BCBA, as well as the 2004 IEP.

BEHAVIOR DURING EVALUATION:

Marcus seemed disorganized during the evaluation, possibly due
to the new environment. He made minimal eye contact and made
little to no response during the evaluation. Marcus seemed
interested in what his mother was doing, but became upset when
she would not provide him with her full attention and exhibited
behaviors of crying and pulling on her clothes.

SELF CARE:
Marcus shows excellent ability to feed himself. He can feed
himself with a spoon. He demonstrates moderate ability to use a
fork, feed himself without spilling, and recognize when food is
hot. Marcus is also moderately able to indicate when his diaper
needs changing, which is a positive step towards independent
toileting. Marcus demonstrates limited ability to manage clothing
for toileting and dressing, including putting on his clothes and
completing fasteners such as buttons, snaps, and laces. He
demonstrates early strengths in undressing, such as taking off
shoes, and removing pants including unsnapping and unzipping.
Marcus also demonstrates interest in changing his clothes when
they have become dirty. He requires assistance when bathing,
and maximum assistance with toileting.

PLAY:
Marcus is excellent at puzzles, and enjoys completing them. He
demonstrates an interest in gross motor and sensorimotor play,
which are early stages of development in play skills. His play is
repetitive and he uses very few toys which he enjoys lining up.
Marcus does not demonstrate the age appropriate functional
play, which is play that explores objects in their intended
capacity (driving a car, holding a phone up to his ear). Marcus
shows interest in playing with his peers and is capable of
imitating movements and actions when a model is provided.
Marcus does not engage in any imaginary play with his peers,
nor does he participate in games on the playground.

EDUCATIONAL PERFORMANCE
Marcus is learning sign language, and has shown the emerging
skill of word imitation. His desire to communicate is present even
though his language is delayed. Marcus demonstrates listening
when addressed by the teacher, and understands the meaning of
the word no which is helpful in the classroom environment. He
demonstrates minimal eye contact and lack of attention to his
teacher and other adults except his mother. Marcus shows a
clear avoidance of school and presents with behaviors within the
classroom including hitting other students, lack of consideration
for others, and impulsivity. Marcus is unable to write
recognizable shapes or letters, and tears the paper when
attempting to use the eraser. He also demonstrates a limited
ability to use scissors.

ROUTINES
Marcus is very consistent in his daily schedules and task
routines. He displays positive reactions to predictability and
shows signs of anticipation for the next step in a process. His
routine at home for sleeping and eating was difficult to establish,
and he reacts adversely when changes are made to his now
established schedule. His personal hygiene routines are rigid,
which inhibits his ability to tolerate instruction for greater
independence.

GROSS MOTOR SKILLS:

Marcus has adequate gross motor skills and good muscle tone.
He does not require supports to sit or stand, and demonstrates
the ability to crawl and walk. He can climb up and down stairs,
jump over small objects, and use low play equipment. He can
occasionally climb on high play equipment and run, which are
skills he would utilize on the playground. He does not
demonstrate the ability to alternate feet when climbing up stairs
or hop on one foot. Overall gross motor skills are not a concern,
except for complex balance skills.

FINE MOTOR SKILLS:

Marcus demonstrates excellent ability to pick up and grasp
objects. He has full use of opposition and pinch, which he uses to
complete puzzles and open doorknobs. He can occasionally use a
writing utensil to make marks. Poor coordination persists as a
challenge for completing more complex writing tasks and in hand
manipulations, for example the small hand movements that are
necessary for clothing fasteners. Fine motor skills are an area of
concern.

VISUAL-PERCEPTUAL MOTOR SKILLS:

Marcus shows strength in matching and sorting shapes (circles,
squares, triangles), colors, and other like objects. He is also able
to complete puzzles well, without the need to test multiple puzzle
pieces before finding the correct piece. He can string large beads
and roll clay into a log with help. Marcus demonstrates difficulty
with directional cues, and reproducing straight lines both in
tracing and cutting. Placing pegs in a pegboard was difficult to
examine due to his lack of interest, however he did not
demonstrate a strong ability to complete the activity.

SENSORY PROCESSING SKILLS:

Marcus shows strengths in sensory processing related to muscle
tone and he measured as typical on the Sensory Profile tool in
sensory sensitivity (how much he notices stimuli within his
environment) and sedentary (his preference for quiet activities
and environments). Per the Sensory Profile, Marcus shows
definite sensory processing differences from the norm in
auditory, vestibular, touch, multisensory, and oral sensory tasks
throughout his day. He is a picky eater and dislikes the sound of
the toilet flushing. Marcus withdraws from touch, and shows
distress during personal hygiene routines (such as face washing).
Marcus shows definite differences from norm in behavioral and
emotional responses to sensory stimulation; for example, he has
difficulty coloring between the lines.

ASSESSMENT AND SUMMARY:

Marcus is making strong gains in development, and shows
strengths in gross motor skills and consistency with routines. He
is showing advances in feeding himself independently. His
difficulties with play and educational performance appear to be
the result of his sensory processing. His pattern of sensorimotor
play indicates a fixation with sensory seeking activities. His
limited attention span and behaviors in the classroom may be
related to the abrasive auditory and visual stimuli. Marcus
struggles with sensory modulation (the brains ability to regulate
its activity) which leaves him in a state of constant go, and
creates an inability to focus on learning new tasks and exploring
new play (such as pretend). Marcuss fine motor skills and visual-
perceptual motor skills, in addition to his sensory processing
difficulties, are areas of concern which appear to underlie his
difficulty with self-care. Specifically, tactile discrimination (the
sensory ability to tell apart objects by feel) and fine motor skills
underlie the ability to get dressed using fasteners (buttons,
zippers, etc.). Visual perceptual motor skills underlie his
difficulty with placing his arm through the armholes accurately,
as well as similar steps in dressing. Visual-perceptual motor
skills also underlie his difficulty with tracing and imitating
shapes

RECOMMENDATIONS AND TREATMENT PLAN:

Occupational therapy would be beneficial to assist Marcus with
his sensory processing, and his fine motor skills. It would also be
beneficial for me to analyze and modify his tasks and
environment to allow for greater success in the classroom. I
recommend that Marcus receive OT twice a week for 45 minutes
for the duration of the school year.

Because of Marcuss sensory processing difficulties, it would be

beneficial for him to be seated away from noise and movement
(i.e. other students). It may be beneficial to place him near the
front of the classroom, so that while looking at the teacher he is
not distracted by the movement of his peers between him and
the teacher. Providing Marcus with some way of satisfying his
need for sensory stimulation (e.g. sitting on an exercise ball
instead of a chair, fidget toys, etc.) may decrease behaviors such
as rocking in his chair and allow him to maintain a seated
position for longer periods. Fine motor skills should be addressed
using toys and games that allow Marcus opportunity to develop
these skills (e.g. cards, wind-up toys, penny jars). Task
modification to make fine motor objects larger is encouraged,
such as using coats with larger buttons.

It was a pleasure meeting Marcus. Please feel free to contact me

at 520-555-8664 if you have any questions about this report.
Sarah Struthers
Sarah Struthers, OTS

This portion would not be part of a typical evaluation report but

for your assignment- please provide

GOALS:

3 LTG with 3 STG under each LTG

LTG1: Improve fine motor skills for self-care

STG1: Marcus will snap 3 snaps independently in 3 out
of 5 trials.
STG2: Marcus will button 3 1 buttons independently in 3
out of 5 trials.
STG3: Marcus will zip 5 of his jacket zipper with
assistance to start the zipper and a 1 zipper pull in 3 out of
5 trials.

LTG2: Improve visual-perceptual motor skills for educational

performance
STG4: Marcus will trace a 3 long thick line in 3 out of 5
trials.
STG5: Marcus will color in a 2 square within accuracy
in 3 out of 5 trials.
STG6: Marcus will match 8 short and long objects (4
crayons and 4 pencils) in 3 out of 5 trails.

LTG3: Improve tolerance to school environment for classroom

behavior
STG7: Marcus will tolerate noise from other students in the
classroom while completing a seated activity for 15 minutes
without inappropriate classroom behaviors (e.g. crying) in 3
out of 5 trials.
STG8: Marcus will try 3 bites of 1 new food at lunchtime in
3 out of 5 trials.
 STG9: Marcus will demonstrate classroom appropriate
movement for at least 15 minutes using fidget toys in 3 out
of 5 trials.

List 1 appropriate treatment activities you might try for this

child- explain them well enough so that I would understand what
you plan to do (how would it be set up, what would it work on,
what frame of reference are you using?)

Marcus would benefit from an activity that improved his fine

motor in-hand manipulation skills such as shift, rotation, and
translation. To focus on this during therapy I would provide a
container of nickels and a paper with a thick and 10 long
zig-zag line drawn on it. I would then draw on his strength of
lining objects and prompt him to line the coins along the line one
at a time, with the coin face up and the top of the coin near the
top of the paper. Once he has mastered picking up one coin at a
time and placing it, I will prompt him to pick up three coins at a
time and place them on the line one at the time. Using the
developmental FOR I would expect that this activity would aide
him in dressing using fasteners.