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ESD Occupational Therapy Evaluation
Education Service District
Early Intervention Program
REPORT DATE: 6/3/99
AGE: 38 months
II. BACKGROUND & REFERRAL REASON
CK was referred for an occupational therapy assessment due to concerns regarding his fine motor skills and sensory concerns. CK was seen at his ECSE classroom on 5/10/99. This therapist was able to talk with CK's father to gain some information prior to testing. This therapist observed CK on this date as well as testing begun. This therapist attempted to see CK on two other opportunities, one at his daycare setting and another at his ECSE classroom setting. These dates were not successful. This therapist finished the testing on 6/2/99.
III. EVALUATION PROCEDURES
Motor Scales-Fine Motor
|OTRIL||5/10/99||-2.33 standard deviations|
|Preschool Developmental Profile
|OTR/L||6/2/99||skills scatter into the 3 year level|
IV. CURRENT LEVELS OF FUNCTIONING
Fine Motor Skills:
On the Peabody assessment CK received a standard deviation score of -2.33 standard deviations. An average score for this area would have been a score of -1 to +1 standard deviation. The score that CK received indicated that his skills are below that expected for his age.
CK does not appear to have established a dominant hand yet for fine motor activities. He was observed on several opportunities to use one hand then switch to the other while performing a fine motor task. He is beginning to display a tripod type grasp (thumb and fingers rather than a whole hand grasp) which is a more mature pattern of grasp for writing or drawing. He does frequently use a whole hand grasp or a pronated type grasp (wrist turned downward). CK was able to copy any patterns presented including horizontal or vertical lines. He would scribble easily. He was able to build a tower of 10 1" blocks using both hands to stack the blocks. He was given several opportunities to copy a pattern made with blocks (train or bridge) he could not do this. He could place the circle, triangle and square in the formboard. Dad reported that he likes to do puzzles at home. He displays a neat pincer grasp when picking up small items (thumb and index finger grasp). He was able to make snipping cuts in paper using a regular preschool scissors. He used a pronated type grasp on the scissors when trying to cut (thumbs down position). He was able to wind a knob on a music box to listen to the music. He was not able to sting I" beads for this therapist but his parents reported that he has been observed to do this one time. CK was not able to unbutton 1" buttons on a model.
CK's attention for these types of activities appears to be very short. He attended as long as this therapist could keep the activities changing frequently. When observed performing project type activities in the classroom setting CK will attend for only very short periods of time. He not only looses visual attention but also removes himself from the situation if permitted.
Dad reported no concerns with vision or hearing. CK demonstrated good visual tracking and fair gaze skills. He maintained gaze on the objects presented for only brief periods of time.
Skills not yet mastered:
Increased attention during fine motor activities, using one hand as a dominant hand, use of preschool scissors for cutting on a line, drawing lines/simple shapes imitatively, imitating bead or block patterns, bilateral hand skills and buttoning/unbuttoning on a model.
CK is observed to move about the classroom a lot. He stays with activities for very short periods of time and with a fair amount of prompting when he does do so. He enjoys opportunities for movement in the classroom and on the playground (swings, slides, jumping, tricycle). He likes the sensory table. Dad reports that CK has had difficulty with having his hair washed in the past but is better now. He added that he likes to touch his mom's hair. Dad reported that he has not observed any concerns regarding noise or sounds. He added that he does okay at malls, movies and likes music. When asked if music ever calmed CK down Dad was not sure if it did. He is observed to put his thumb in his mouth frequently when in the classroom. Teacher stated that he also puts toys in his mouth frequently. Dad reported CK does stuff food. He is doing better at eating a variety of foods but this is still a bit of a concern.
When asked about self-help skills Dad reported that CK is assisting with undressing (shoes, socks and shirts). He has more difficulty with dressing. He allows his parents to assist hirn with toothbrushing. He is not potty trained. Parents area able to place him on the potty. He continues to wear diapers.
Skills not yet mastered:
Potty training, continue to develop dressing skills, decreasing need for oral stimulation, perhaps increasing his variety of foods and proper chew, bite and swallow techniques to avoid stuffing.
CK's fine motor skills are delayed for his age.
- Recommend opportunities to increase his fine motor skill development as well as his self-help skills in the classroom setting.
- Recommend that he receive occupational therapy services to address the above as well as to provide suggestions for techniques to increase his attention for classroom activities.