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This eval was generated in record time using Use our online software to generate your OT evaluation reports in a fraction of the time.General InformationNameGemma BettencourtDate of EvaluationAugust 19, 2018Date of birth1.18.2008Chronological Age10SchoolLake Ridge AcademyGrade4EvaluatorJason Gonzales OTRLGenderFemalePurpose of EvaluationThe purpose of an Occupational Therapy assessment within the school setting is to determine whether OT services are necessary for the student to participate in the curriculum, develop and retain skills to meet academic goals. Test scores are not viewed alone in determining the need for service but are considered in the context of many other issues including, but not limited to; existing diagnosis, neurological issues, functional developmental skill level, cognitive ability, specific educational goals and objectives, and/or class placement. When a recommendation is made for therapy, the occupational therapist and the Educational Team need to consider if support from an OT is necessary and required for the student to access, participate and make progress in the educational setting. The Educational Team needs to determine if the supports recommended by the OT require OT as an ongoing service, or if these supports and accommodations could be implemented by other Educational Team members. Occupational Therapy services can be provided through skill building sessions, classroom collaboration, monitoring, consulting, or a combination of those modalities, depending on which delivery model will best serve the needs of the student in the least restrictive environment.Gemma is being assessed for occupational therapy as part of an initial assessment to determine whether her needs significantly impact her academic performance within the realm of occupational therapy. Occupational therapy eligibility and service frequency will ultimately be determined at the time of the IEP meeting.Evidence of InformationGemma used verbal language as a mode of communication during assessments. The assessment was completed in the OT room, in the general education classroom, on the playground and at lunch.Assessments Administered:Records reviewsParent interviewsTeacher interviewsObservationsSensory Profile 2 School Companion (SP2)Developmental Test of Visual Perception (DTVP-3 or A)Validity StatementThe assessor used a combination of assessment methods and tools to provide an authentic and accurate profile of Gemma's learning style, preferences, strengths, and needs across environments and settings. The assessor used this information to identify goal areas and identify supports and strategies that are essential for her progress in her educational program. Results of this assessment are believed to be a valid representation of her abilities.Background and Presenting ConcernsGemma is a 10-year-old student currently attending Lake Ridge Academy in a 4th grade resource classroom. Per current Individual Education Plan (IEP), Gemma's primary classification is under Other Health Impairments (OHI). She has been receiving special education services including Occupational Therapy, Speech Therapy, Academic Support and Counseling. Occupational therapy services were implemented to address fine motor skills and sensory processing difficulties in the classroom.Gemma currently lives with her mom, dad, and brother. According to Ms. Bettencourt, her mother, she receives private occupational therapy (OT) services. Gemma has a diagnosis of ADHD. She does not have any allergies or history of surgeries. She is currently taking Ritalin for attention. She passed her most recent hearing and vision screenings.The assessor gathered data about Gemma's functional vision skills through informal observations. She demonstrated the ability to track moving objects, diverge her eyes as an object moves farther away and maintain focus on objects for an appropriate amount of time. She had difficulty converging her eyes as an object moves closer. She often complains of blurred vision and headaches. She has been observed to have difficulty concentrating, squinting and rubbing her eyes when reading or writing. Due to her visual skills, she may demonstrate slow reading, difficulty reading and word and letter reversals.Jennifer is concerned with Gemma's ability to produce legible writing, keep up with academics, and improve focus and attention.. Mrs. Jimenez, Gemma's teacher, reported that she is very social and has lots of friends. She always wants to be the helper in the classroom and enjoys reading. Mrs. Jimenez is concerned with her ability to produce written work. She reported that Gemma's handwriting is difficult to read and she appears to be frustrated during writing tasks. She needs constant redirection and verbal prompts for focus and attention during rug time and seated work.OT ProfileGemma likes to listen to music, dance, and watch YouTube videos and cartoons.. She stated that she likes school because she can play with her friends. Her favorite subject is math because "it's easy". She doesn't like writing because it's boring and her handwriting "isn't the best."Gemma stated that she would like to be able to draw and write better and faster. Gemma wants to be ballerina when she grows up. She learns best using a multi-sensory approach to learning.The assessor gathered data about Gemma's class participation and in class supports through observations, records review, and consultation with Gemma and Ms. Bettencourt. The teacher and school staff have been supportive and accommodating to Gemma's needs. When necessary, she is allowed to have movement breaks for self-regulation. A visual schedule is used for classroom routines. She does not appear to be bullied at school. At home, she has a very supportive family.Collaboration between therapists and staff has been poor which makes generalization to the classroom more difficult. There has been inconsistent communication between school and family through email, phone, or notes to update progress and/or address any concerns or comments. Homework takes too long and is often not completed or returned.Gemma participates in ballet class on Thursdays and gymnastics on Saturday mornings. In the summer she plays in a soccer league but doesn't really care for it. Jennifer reported that Gemma has irregular sleep patterns and often wakes up in the middle of the night.Behaviors During TestingThe testing environment had visual distractions that affected Gemma's ability to focus on a given task. She needed minimal verbal cues to transition between activities. She was able to follow written, verbal and multi-step directions. She was able to answer and ask questions appropriately. Throughout the evaluation process, Gemma displayed an appropriate affect. She was able to maintain appropriate eye contact during interactions with assessor. When participating in tabletop activities, she displayed fair sitting posture. She needed moderate verbal prompts for focus due to difficulty maintaining visual attention and following verbal directions.Motor Skills / Sensory Motor DevelopmentPlayground AccessGemma is able to safely navigate the play structure at recess. Demonstrating balance and coordination, she was able to climb a ladder up and down, use the slide, climb on the monkey bars and use the steps. She was observed playing soccer with her friends at recess.Physical Education (PE) AccessAssessor consulted with Gemma's PE teacher and observed her in class. Her participation in PE is impacted by her ability to pay attention. Gemma is able to hop on each foot, gallop, coordinate jumping jacks, kick a moving ball and throw a ball accurately.Classroom, Campus NavigationGemma was able to safely navigate the various surfaces at school including, concrete, dirt and steps. At school, she is able to find needed items, move around obstacles such as chairs or desks, stand and walk in a line with peers and locate rooms (office, nurse, bathroom). She was observed to be able to transition around campus while carrying small items, a backpack and a lunch tray in the cafeteria. Postural Skills for Educational ActivitiesIn the classroom, Gemma's chair and desk are the appropriate height, accessible and in a functional location. She frequently changed positions during seated work. When sitting on the floor, she frequently changed positions but maintained personal space.Classroom Tool UseGemma uses a functional right-handed grasp when completing fine motor activities such as writing, coloring, and drawing. During pen to paper tasks, she displayed a dynamic tripod grasp and adequate pencil pressure. Her thumb and finger make an open web space reducing the amount of pressure needed to hold onto the pencil, which may translate into decreased hand fatigue. Using her opposite hand, Gemma automatically stabilized the paper. She is able to use scissors independently. She can cut simple geometric shapes (circle, square, triangle) and irregular complex shapes. She was able to manipulate a stapler, tape dispenser and pencil sharpener. When given a shape to color, Gemma colors 85-100% of the image. She is able to color an image with minimal (<3) deviations (1/8" outside of lines). She is able to draw a person with 12 recognizable parts. She is able to independently draw squares, diamonds and circle.Technology AccessibilityGemma is able to use a keyboard, navigate a mouse, access applications or programs on a computer and use a tablet or iPad. She was able to use the hunt and peck method to locate letters on the keyboard to type. She reported that she prefers typing to writing. It is recommended that Gemma use a word processor for written output when necessary. She can type 15 words per minute (wpm).Written ExpressionGemma has demonstrated the ability to produce legible written work but does not do it consistently. Compared to her peers, Gemma tends to write too slowly which can impact her output. When writing, she is able to identify where to start and stop on writing paper, write from left to right, work top to bottom and generate her own ideas. From memory, Gemma is able to independently print the upper and lower case letters of the alphabet (letters could be identified as the intended letter). She is able to independently write the numbers 1-10. Her writing has inconsistent spacing, letter formation and line orientation. She is able to copy from near sight (90% accuracy) and far sight (85% accuracy). When copying, Gemma would often miss punctuation and not use capital letters properly.Developmental Test of Visual Perception (DTVP-3 or A)The DTVP-3 is a battery of 5 subtests that measure different but interrelated visual perceptual and visual motor abilities. It allows for a comparison between motor reduced visual perception and visual motor skills. Scaled scores that are 13 and above reflect above average ratings; scores between 8-12 reflect average ranges; 6-7 reflects below average and 5 and below reflect poor rating. Scores are as follows:Subtest DescriptionScaled Scores (SS) (Average 8-12)PercentileDescription of StatisticsEye-Hand CoordinationChildren are required to draw precise straight or curved lines in accordance with visual boundaries.55PoorCopyingChildren are shown a simple figure and asked to draw it on a piece of paper. The figure serves as a model for the drawing.937AverageFigure-GroundChildren are shown stimulus figures and asked to find as many of the figures as they can on a page where the figures are hidden in a complex, confusing background.937AverageVisual ClosureChildren are shown a stimulus figure and asked to select the exact figure from a series of figures that have been incompletely drawn. In order to complete the match, children have to mentally supply the missing parts of the figures in the series.55PoorForm ConstancyChildren are shown a stimulus figure and asked to find it in a series of figures. The targeted figure will have a different size, position, and/or shade, and it may be hidden in a distracting background.1163AverageComposite Index (Average 90-100)PercentileDescription of IndexOverall General Visual PerceptionIndex = 8212Below AverageMotor Reduced Visual PerceptionIndex = 9025AverageVisual Motor IntegrationIndex = 8719Below AverageGemma was able to complete the standardized assessment in the appropriate time frame. She demonstrated a strength in the Motor Reduced Visual Perception area as evidenced by her scores. When copying shapes from near sight, she was able to use smooth and fluid lines. Gemma was able to identify specific figures within a cluttered and complex background. She demonstrated the ability to match two figures that vary on one or more discriminating features (i.e. size, position, or orientation).Gemma displayed a significant delay in her Visual Motor Integration Skills. She had difficulty drawing straight and curvy lines within visual boundaries. She was not able to recognize a stimulus figure that was not completely drawn. Due to these weaknesses, Gemma may reverse letters, numbers, or words when copying or writing, have poor recall of visually presented material and/or have difficulty copying from the board. Her short attention span during testing may have impacted her scores. Her scores appear to be a good indicator of her functional abilities. Although she demonstrated weaknesses, she is still able to produce legible and functional written work.Social / Emotional / Behavior SkillsSocial Participation in School EnvironmentsGemma will respond to her peers and adults. She often initiates interactions with peers. Teacher reported that Gemma is very friendly and nice to all of her peers. She has many friends. Parent reported that Gemma enjoys playing with her cousins and her neighbors. She participates in several organized sports and has recently joined the Girl Scouts. At recess, she usually plays with her peers. She was able to transition between classrooms. She respects other people's personal space. She will play games independently. During group activities, Gemma is able to follow rules, interact with peers, tolerate losing, take turns and share materials.Emotional Regulation for School ParticipationGemma is a pleasant and cooperative student. She is able to express her needs and wants. When asked, she is able to describe her own emotional or physical status. She has demonstrated a low frustration tolerance but is easily redirected. She responds well to verbal and visual supports to help keep her calm and focused during the day. Gemma tends to use various self-regulation strategies to keep engaged at school, such as heavy work, sensory diet and movement breaks. Heavy type work activities include carrying items, taking down/putting up chairs, or performing jobs for the teacher (e.g. three hole punch, stapler, etc.).Sensory ProcessingSensory processing is the brain's ability to orient, regulate, and use multi-sensory information to successfully complete activities and make the appropriate adjustments to assure ongoing success. Sensory processing skills help lay the foundation for a variety of behaviors and skills such as emotional affect, the ability to maintain focus and attention, fine motor and visual motor skills, and the ability to transition between activities.Sensory Profile 2 School Companion (SP2)The SP2 is a questionnaire used to gather information about a child's ability to adapt to/cope with basic sensory input, grouping them into sensory processing systems: auditory, visual, touch, movement, body position, and oral. These patterns may affect student's ability to function, participate, and perform within school, home, and/or community environment. It is meant to complement with other clinical observations/tools, and the scoring should be taken within the context of all information gathered. There are different norm referenced, standardized caregiver and/or teacher questionnaires, ranging from infancy through school age.Caregivers and/or teachers rate behavioral statements on a 5-point Likert scale and scoring is looked at in terms of Typical Performance, Probable Difference, and Definite Differences.SectionRaw ScoreTypical Functioning RangeInterpretationAuditory26/356-15Much More Than OthersVisual31/356-17Much More Than OthersTouch14/405-15Just Like the Majority of OthersMovement17/406-17Just Like the Majority of OthersBehavioral27/559-22More Than OthersQuadrantsRaw ScoreTypical Functioning RangeInterpretationSeeking/Seeker28/407-19Much More Than OthersAvoiding/Avoider20/608-21Just Like the Majority of OthersSensitivity/Sensor28/5510-23More Than OthersRegistration/Bystander13/6510-28Just Like the Majority of OthersSensory Pattern/Quadrant Summary:Seeking/Seeker -- "obtains"; finds interest and pleasure in sensationsAvoiding/Avoider -- "bothered by"; necessity to control or avoid sensationSensitivity/Sensor -- "detects"; ability to acutely notice sensationsRegistration/Bystander -- "misses"; general awareness of sensationsOur sensory threshold is an indication of how much input it takes to activate our system responses. A low threshold indicates that it does not take much to activate. Sensory sensitivity behaviors are acting in accordance to our threshold, and sensory avoiding behaviors are acting to counteract the threshold.Raw ScoreTypical Functioning RangeInterpretationSchool Factor 137/6510-28More Than OthersSchool Factor 235/5010-24More Than OthersSchool Factor 335/609-23Much More Than OthersSchool Factor 415/456-16Just Like the Majority of OthersSchool Factor 1: Supports - measures a student's need for external supports to participate in learning; often a high amount of sensory input is needed to get ready for learning.School Factor 2: Awareness - measures the student's awareness and attention within the learning environment; often these students are pulled away from learning due to other stimuli in the room.School Factor 3: Tolerance - measures the student's tolerance within the learning environment, no longer distractible but avoidant behaviors or hypersensitivity.School Factor 4: Availability - measures the student's availability for learning within the environment as it relates to disengagement due to avoidant behavior or failure to detect important stimuli to then learn.Mrs. Jimenez, Gemma's teacher, completed the questionnaire.TouchThe tactile system, or touch system, refers to stimulation reaching the central nervous system from receptors in the skin.Occasionally, Gemma may react to various tactile experiences negatively. She constantly fidgets with objects.Balance and Motion (Movement)Through receptors located in the inner ear, the vestibular system provides information on the position of the head in relation to gravity and influences posture, balance, and coordination.Gemma appears to be able to demonstrate balance, movement, and postural control appropriately. She plays or fiddles with objects, can be fidgety or disruptive when close to other people and slower to participate in physically active tasks.Hearing (Auditory)The auditory (hearing) system processes sound information. Auditory discrimination is the ability to differentiate between various important and un-important sounds within the environment.Gemma demonstrates consistent reactions when processing auditory stimuli. She does not respond to her name being called. She frequently misses verbal directions and has difficulty participating in group activities where there is a lot of talking.VisualThe visual system uses the eyes to receive information and interprets what is seen.Gemma demonstrates consistent reactions when processing visual information. She misses written directions, watches people move around the room and leaves items blank on a busy worksheet, despite knowing the answer.Behavioral ResponsesBehavioral responses are the actions of a person, usually in relation to their environment.Gemma has difficulty understanding and processing sensory information, which can produce inappropriate responses in everyday life. She does things in a harder way than is needed and demonstrates poor frustration tolerance.Gemma's scores may be elevated or impacted by unrelated sensory processing issues such as medical, developmental, or cognitive reasons. Gemma has a diagnosis of ADHD. Students with ADHD can demonstrate sensory behaviors. These actions can be caused by inattention and not by the environment.Based on the results from the Sensory Profile 2, Gemma appears to be a Seeker (finds interest and pleasure in sensations), Avoider (necessity to control or avoid sensation), Sensor (ability to acutely notice sensations) and Bystander (misses or appears not to detect sensory information). Due to her difficulty in understanding some sensory information, Gemma may demonstrate behaviors that impact her ability to function within her environment. She demonstrates behaviors that add more intense sensation such as chewing on clothing, fidgeting, or constantly moving around. Gemma can be easily overstimulated. She is drawn to or distracted by stimuli in environment. She can appear introverted or lack the motivation to participate in activities. These behaviors can impact her ability to make and maintain friendships, initiate and complete tasks and complete worksheets. Gemma may benefit from activities that incorporate multiple senses such as hands on activities or sitting on a therapy ball, participating in "heavy work" activities and using fidgets or manipulatives.All sensory processing preferences have advantages and disadvantages. There are no inherently good or bad sensory processing preferences. The context of the environment, and the task at hand, determine whether an individual’s sensory processing preferences are an advantage or disadvantage. Therefore, we need to “consider if sensory processing is interfering with Student’s activities or aspects of her activities of daily living are not satisfying to her” (Dunn 2002).Adaptive Skills / Self-help SkillsSchool Activities of Daily Living (ADL)School ADL's include grooming, hygiene, toileting, mealtime and clothing management as they relate to participation in the student's educational environment.The assessor gathered data about Gemma's ADLs through observations and consultation with Ms. Jimenez and Ms. Bettencourt. She is able to use utensils for feeding, drink from a cup, open containers at lunch or snack and manage her clothing before and after toileting at school independently. She requires verbal and/or visual cues to wash her face and wash and dry her hands at school. She requires physical prompts such as hand over hand or light touch to tie her shoe laces at school.School Instrumental Activities of Daily Living (IADL)School IADL's include organization of personal materials (backpack, desk, cubby), safety awareness, and learning communication devices such as phones and computer.The assessor gathered data about Gemma's IADLs through observations and consultation with Ms. Jimenez. She is independent in retrieving, gathering, and putting away her materials, safety awareness, learning communication devices such as phones or computer and following her class schedule/routines. Gemma requires verbal or visual support for managing her notebooks and papers and keeping her desk organized.Task Organization/Pre-Vocational Job SkillsThe assessor gathered data about Gemma's vocational skills through observations and consultation with Ms. Jimenez. She is able to initiate tasks and follow written or verbal directions independently. She requires verbal and/or visual cues to attend to tasks and complete multi-step activities in an appropriate time frame.Vocational/Life SkillsGemma demonstrates the ability to twist, bend, reach, carry items and grasp items in her environment safely and easily. Her attention impacts her ability to participate in vocational activities and may require modifications.Self-AdvocacyThe assessor gathered data about Gemma's self-advocacy skills through observations and consultation with Ms. Jimenez and Ms. Bettencourt. She demonstrates good self-advocacy skills. She is able to raise her hand to ask a question, stick up for herself, express her needs and wants clearly and seek out help from peers or adults when necessary.SummaryGemma is a pleasant and cooperative student. She demonstrates a relative strength in the areas of playground access, postural skills for educational activities, movement skills for vocational activities, classroom tool use, technology accessibility and social participation. She appears to have functional range of motion and strength for the educational setting. She participates in PE to the best of Gemma's ability. She is able to navigate her school environment and find classrooms and offices. She is able to raise her hand to ask questions and express her needs and wants.Currently, there are several modifications and accommodations being implemented throughout Gemma's school day, which allows her to access her educational environment as it relates to written expression and emotional regulation. These strategies include heavy work, movement breaks, modified paper, graphic organizers, and token reward system. She appears to be benefiting from most of these strategies but she continues to need support.Gemma's difficulties in the areas of written expression and emotional regulation affect her ability to engage in structured learning activities at school. Gemma scored in the Very Poor Range on the Visual Motor Integration Section of the DTVP-3 which can impact her ability to copy from the board and produce legible work. She continues to have difficulty writing the alphabet from memory and can be easily frustrated. Gemma can successfully use and understand some sensory information, and has difficulty understanding and using other sensory information. On the Sensory Profile 2, she scored in the Definite Difference/Much More than Others in the School Factors 1 and 3. She scored the Probable Difference/More Than Others in School Factor 2 and 4. Gemma would need extra sensory input throughout the day to get her sensory needs met. At this time, occupational therapy services are recommended to address the areas of need mentioned above. As Gemma's functional participation improves it is anticipated that occupational therapy will be discontinued unless additional needs are identified by the individual education program team.RecommendationsAllow Gemma extra time with written assignments.Allow Gemma to use a word processor for written output.Use graphic organizers.Use modified paper such as graph paper, raised line paper, or enlarged paper.Multi-sensory approach to writing in therapy sessionsAllow frequent movement breaks to help with regulation including many "heavy type work" activities such as carrying the lunch cart, running books back to the library, taking down/putting up chairs at the beginning/end of the day and performing jobs for the teacher (e.g. three-hole punch, stapler, etc.).Allow Gemma to stand instead of sit at her desk.Provide positive reinforcement.Provide short breaks when refocusing is needed.Provide Gemma with frequent movement breaks throughout the day (especially during extended reading/writing activities) in order to improve overall attention, focus and provide a visual "break" (classroom).Use two different colored shoe laces for shoe tying.Allow extra time for task completion.Explore strategies for organizing desk materials (such as use of a desk organizer, a visual "map" of where materials go, and/or a desk "buddy" to help.Break down tasks into manageable units.Use of checklistsVisual demonstrations?Signature: _______________________________________ Date: _______________ ................
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