Occupational Therapy Evaluation

Child’s age: 4 years, 6 months

Reason for referral: Kira was referred for an occupational therapy evaluation as part of a full child study team evaluation. Kira was previously evaluated by this therapist last year. Concerns at that time centered around her social development and attention to task. Kira has attended preschool this year. While growth has been noted, concerns persist in the aforementioned areas.

Behavioral Observations: Kira entered the evaluation room with this tester, by herself, as her mother completed an interview with the social worker.  She was pleasant and friendly but announced that she did not want to play. Nonetheless, she was cooperative when asked to perform a variety of gross and fine motor activity.  While she preceded her performances with “I don’t want to” she could be encouraged to participate. This was Kira’s second evaluation on this morning.

Kira’s attentional behavior appeared to be diminished. Eye contact could be elicited but was fleeting in length and not offered frequently on her own initiative. Response time appeared to be notably delayed. Kira often appeared to be staring in to space. Sometimes she seemed to forget what she was supposed to do. On other occasions after a long delay, she would say “I don’t know how to do that.” While performing many gross and fine motor activities, Kira failed to watch what she was doing, which interfered with the accuracy of her work. Kira talked freely throughout the evaluation period: conversations were not always topical. Also noted was that Kira tended to hold her breath while concentrating, letting it out suddenly.

Gross Motor:  Kira displayed a full repertoire of primary movement patterns, with a fairly complete range of secondary, more integrated movement patterns. Active range of motion and muscle tone appeared to be generally within normal limits. Overflow observed last year (arms in midguard posture and hand flapping) seemed to have lessened. The quality of her movements in terms of speed and agility appeared to be within normal limits. Kira tended to move spontaneously, without careful regard to motor planning other directed movements.

According to the Michigan Preschool Profile, Kira functioned on a 4 year to 4 year 6 month level in gross motor development, with scattering of skills in the 3 year 6 month to 4 year 6 month level. Kira walked with heel to toe articulation.  She was able to walk backwards and in a heel to toe fashion.  She stood on one foot for one to two seconds. She jumped in a forward direction a distance of about twelve inches. By report, she pedals a riding toy, and uses the slide and swing, although she does not yet pump a swing. She was able to toss a ball, with inconsistent control.  Inattention interfered with her ability to catch the ball.

Perceptual/Fine Motor: Kira used her hands in a fairly coordinated, assistive fashion, displaying a preference for her right hand. Mild hypermobility of the joints of the hands was noted. Manipulation was usually performed in the fingertips, although when inattentive, palmar control was used. She displayed a wide range of grasp patterns with pincer grasps occasionally being lateral. Release appeared to be immaturely developed in both control and precision in placement, again being modified by inattention to task.

According to the Michigan Preschool Profile, Kira functioned on a 3 year 6 month level, with skills widely scattered in the 2 years 6 months to 4 year 6 month range. She stacked eight one inch cubes and duplicated building a four cube train and a three cube bridge using trial and error but did not build the five cube gate or six cube pyramid. She did not complete the rotated two piece puzzle but did complete the simple five piece puzzle. Again, Kira’s approach was not well organized, and she tended to retry the same piece in the improper place repeatedly. She placed six pegs in a pegboard in ten seconds.

Kira held a pencil in her right hand, in a digital supinated grasp. She copied a vertical and horizontal line and a circle and attempted to copy a cross.  She printed her name with some assistance. She drew a seven part man upon request. She attempted to trace within a square template. Kira attempted to cut on a line, with some success.

On the Ernhardt Developmental prehensile assessment, she functioned on a 3 year 6 month to 4 year level. On the design copying test from the SCSTI she achieved a standardized score of – 0.1 (where scores above + 1.0 SD and below -1.0 are considered increasing significant.)

Self Care: Mrs. Baker reported that Kira is completely toilet trained, including at night. She dresses and undresses herself. She can undo snaps and zippers. For feeding she uses a fork and spoon and can pour from a small pitcher.

Summary:  Kira was referred for an occupational therapy evaluation as part of a full Child Study Team evaluation. Her behavior was marked by inattentiveness and difficulty planning and organizing herself for movements and activities. Gross motor functioning was essentially within normal limits, although movements were spontaneous and not well planned. Perceptual/fine motor development was judged to be mildly to moderately delayed, with a wide scattering of skills up to age level. Inattention hampered her performance in all areas tested.

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