Occupational Therapy Evaluation

Child’s age:  3 years, 8 months

Background: Kira was referred for an occupational therapy evaluation by staff from Project Child’s Assessment service because of concerns with gross and fine motor development. Mrs. Baker originally brought Kira to Project Child because of concerns about her social abilities and questionable attention to task.

Kira is the product of a full term pregnancy, with delivery achieved through Cesarian section due to a breech positioning. Mrs. Baker reported her recollections of gross motor milestones being mildly delayed, although independent ambulation was achieved by one year. Medical history was remarkable in that Kira was born with congenital torticollis, which has since resolved. Health has been generally good. Kira attends nursery school.

Tests Administered: 

Michigan Early Intervention Developmental Profile

Michigan Preschool Profile

Ernhardt Prehensile Profile

Parent Report

Observation

Behavioral Observations: Kira entered the evaluation room with her mother, appearing fairly comfortable and interested in her environment. She sat at the table when directed to do so.  Eye contact could be elicited but was fleeting, particularly as language or task demands became more persistent. Kira was generally cooperative and happy, although she seemed to need to be encouraged to participate in dialogue. Mrs. Baker reported concerns that she needs to direct Kira’s play and that she frequently reverts to hand flapping episodes. Occasional episodes of hand flapping were observed during this assessment, but not in an uncontrollable fashion. She also held one hand in the air, while manipulating with the other hand.

Kira benefited from focusing prompters to direct and maintain her attention to task. She occasionally became fidgety in her chair. She seemed more distracted by her own movements and thoughts than by external stimuli.

Gross Motor: Kira displayed a full repertoire of primary movement patterns, with a fully complete repertoire of secondary more integrated movements. Active range of motion and muscle tone appeared to be within normal limits as well. Overflow was observed on occasion as noted previously, with shaking of the arms, as well as occasional fisting, and oral overflow. The quality of her movements was judged to be age appropriate.

According to the Michigan Preschool Profile, Kira functioned on a 3 year 6 month level. She walked with heel strike, and ran fairly smoothly. Mrs. Baker reported that Kira ascends and descends stairs in a reciprocal fashion. She was able to jump twelve inches in a forward direction and repetitively. She stood two to three seconds on one foot. By report, Kira uses the slide, climbing bars and swings on the playground. She pedals a riding toy as well.

Perceptual/Fine Motor: Kira could use her hands in a coordinated, assistive fashion, displaying a preference for her right hand. She manipulated objects comfortably in her fingertips. A very mild tremor was occasionally evident in the hands in unstable postures. Release appeared immaturely developed in both control and precision in placement. Kira had difficulty isolating the movements of her thumb and individual fingers imitatively.

According to the Michigan Preschool Profile and EDP, Kira functioned on a 30 to 32 month level in perceptual/fine motor development, achieving a basal score of 28 months and displaying a scattering of skills up to 3 years 6 months. She was able to stack 6 one inch cubes, and aligned the blocks. She did not actually duplicate building a 4 cube train. She completed the three piece formboard in a forward and reversed presentation. She did not complete the rotated two piece puzzle. She placed six pegs in a six holed pegboard in 19 seconds.

Kira held a marker in a static tripod grasp. She was able to copy a vertical, horizontal and diagonal line, and a circle. She drew an eye, an ear and some hair on a complete-a-man drawing. Kira held scissors in both hands, and is mastering snipping. Kira achieved a 3 year level on the Erhardt Prehensile Profile.

Self Care: Kira is toilet trained during the day, but not at night. She eats using a spoon, and occasionally fork. She spreads very little. She can take off her socks, shoes and underwear, and put on her underwear, and sweatshirts.  She is cooperative in dressing and not yet handling fasteners.

Summary:  Kira was referred for an occupational therapy evaluation because of concerns about hand flapping, difficulty involving herself in play, and delays in gross and fine motor development. Gross motor abilities were judged to be within normal limits. Perceptual/fine motor abilities are judged to be moderately delayed in both quality and skill achievement. Overflow, as noted by Mrs. Baker, was also observed. She will probably gradually outgrow this behavior.

Recommendations:

  1. Kira has been referred to the Perceptual/Motor Clinic. If vacancies are not available, she will be placed on the waiting list.
  2. Mrs. Baker may be able to gradually lead Kira to making her own decisions about play by providing two or three choices, start her on the activity, then encouraging her to play independently for increasing periods of time.
  3. Kira should be encouraged to give and maintain eye contact, by using the directive “Look” (point to eye) and delay speaking to her until she does look at speaker.
  4. Games that encourage Kira to follow directions, move slowly, or sit quietly may also help (i.e.-Giant Steps, Follow the Leader, Simon Says, etc,)

 

 

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