OccupationalTherapyEvaluation

Name:
JasonGonzales

Dateofbirth:
11/09/2004
School:
BowmanElementarySchool
Age:
10
Grade:
4th
Examiner:
ArmandGonzales
Dateofevaluation:
6/27/2016

PurposeofOTEvaluation:
ThepurposeofanOccupationalTherapyassessmentwithintheschoolsettingistodetermine
whetherOTservicesarenecessaryforthestudenttoparticipateinthecurriculum,developand
retainskillstomeetacademicgoals.Testscoresarenotviewedaloneindeterminingtheneed
forservicebutareconsideredinthecontextofmanyotherissuesincluding,butnotlimitedto
existingdiagnosis,neurologicalissues,functionaldevelopmentalskilllevel,cognitiveability,
specificeducationalgoalsandobjectives,and/orclassplacement.Whenarecommendationis
madefortherapy,theprimaryaimasaneducationallyrelatedserviceistoimprovethestudents
abilityindevelopingfoundationalskillstoparticipateinandlearnfromtheireducational
program.OccupationalTherapyisnotintendedtooptimizeskilllevel,buttoimprovetheability
tobenefitfromintheinstructionalprogram.OccupationalTherapyservicescanbeprovided
throughdirectservices,IndividualorSmallGroup,monitoring,consulting,oracombinationof
thosemodalities,dependingonwhichdeliverymodelwillbestservetheneedsofthestudent.

ReasonForReferral:

Thisevaluationwascompletedaspartofaninitialevaluationforspecialeducationservicesand
willhelpidentifycurrentoccupationaltherapyrelatedstrengthsandweaknessesrelevantto
Jason
sschoolparticipationneeds.

BackgroundInformation:
Jasonisa10yearoldboythatattendsBowmanElementarySchool.Heiscurrentlyina4th
gradegeneraleducationclassroom.Jasonwasreferredforanoccupationaltherapyevaluation
duetoFinemotorconcernsHecurrentlyreceivesOccupationaltherapy,academic
support,resource.Jasonenjoyseating.Whenhegrowsuphewantstobesomethingspecial.

MethodsofAssessment:
SensoryProfileTeacherQuestionnaire,TheDevelopmentalTestofVisualPerception3rd
Edition(DTVP=3)


OBSERVATION:
Jasonisapleasantandcooperative10yearoldboy.Hewasevaluatedduringthreesessions
thatrangedbetween3045minuteseach.Heneededmoderateverbalprompts(35)and
participatedinallactivitiestothebestofhisability.Thetestingenvironmentwaswasquietwith
nodistractions.Heansweredandaskedquestionsappropriately.Jasondisplayedappropriate
affectandhissittingposturewasgoodduringfinemotoractivities.neededminimalverbaland
visualprompts.Jasonwasabletofollowverbalandwrittendirections.Hewasmotivated
throughouttheevaluationanddidnotrequireanymovementbreaks.BasedonJasonsefforts,
theseresultsarebelievedtobeagoodindicatorofhisfunctionalskills.

FineMotorSkills:
JasonusedaRightdynamictripodgraspgraspwhencompletingfinemotoractivitiessuchas
writing,coloring,anddrawing.Jasonisabletocutirregularshapes..Heisabletoprintwas
abletobothupperandlowercaseletters..ThequalityofJasonshandwritingisGood

GrossMotorSkills:
Jasonappearstohavefunctionalrangeofmotionandstrengthfortheeducationalsetting.
Jasonisabletonavigatehis/herenvironmentindependently..Hecanaccessallthestructures.
JasonYestothebestofhis/herability.

VisualPerceptualSkills:
VisualPerceptionreferstothebrainsabilitytomakesenseofwhattheeyessee.Thisisnotthesameas
thetermvisualacuities,whichmeanshowclearlyapersonsees(forexample20/20vision).Aperson
canhave20/20visionandstillhaveproblemswithvisualperceptualprocessing.Goodvisualperceptual
skillsareneededforreading,writing,cutting,drawing,completingmathproblems,aswellasmanyother
skills.Visualperceptionisanintermediatestepininformationprocessingbetweensensationand
cognition.Perceptualtasks,therefore,canbedifferentiatedfromsensation(e.g.,visualacuity)and
cognitiveprocessingtasks(e.g.,readingcomprehension).Visualperceptionandvisualmotorintegration
rd
wereassessedbyusingtheDevelopmentalTestofVisualPerception3
Edition(DTVP3).

DevelopmentalTestofVisualPerception3rd

Edition(DTVP3)
measuresbothvisual
perceptionandvisualmotorintegration.TheDTVP3hasfivesubtests(2visualmotor
integrationand3visualperceptual).Itrequiresintegrationofboththevisualperceptionandthe
motorcoordinationskillstoreproducegeometricformsofincreasingcomplexity.Thistest
typicallycorrelateswithdrawingskills,handwritinglegibility,accuracyinformation,andreading
skills.

Subtest

RawScore

ScaledScore

PercentileRank

EyeHand

Coordination
Copying

FigureGround

VisualClosure

FormConstancy

Composite

SumofScaled
Score

Composite
Index

PercentileRank

VisualMotorIntegration

MotorReducedVisual
Perception

GeneralVisual
Perception

JasonscoredintheSuperiorrange(120129)inareaofVisualMotorIntegration.Hescoredin
theSuperiorrange(120129)intheareaofMotorReducedVisualPerceptionandinthe
Superiorrange(120129)GeneralVisualPerception.

SensoryDiscriminationandSensoryModulation
Sensorydiscriminationisthewayoneorganizesandinterpretssensoryinformationtothen
utilizeforskillfulperformance.Problemswithsensorydiscriminationcontributetodifficultiesin
specificaspectsofcoordination,motorplanning,andskilldevelopment.

Modulationofsensoryinformationreferstohowournervoussystemmaintainsanoptimallevel
ofarousalsothatwecanfocusandmakeuseoftheInformationfromoursenses.Ifthebrain
doesnotfilterandinterpretsensoryinformationcorrectly,thenanindividualmaybeover
responsive,underresponsive,orvaryinresponsetosensoryinformation,whichcanaffecttheir
attention,behavior,emotions,andmotorresponses.

ResultsfromSensoryProfileTeacherQuestionnairecompletedby

Quadrant

Description

Registration

TypicalPerformance

Seeking

DefiniteDifference/MoreThanOthers

Sensitivity

TypicalPerformance

Avoiding

ProbableDifference/MoreThanOthers

SchoolFactor1

TypicalPerformance

TypicalPerformance

ProbableDifference/MoreThanOthers

TypicalPerformance

SchoolFactor2

SchoolFactor3

SchoolFactor4

QuadrantScoresExplanation

Registration
:
Scoresintheprobable/definitedifferencerangerepresentstudentswholikely
misssensoryinputthatprovidecuesaboutwhatisgoingoninthecontext.Thebrainmaynot
begettingwhatitneedstogenerateresponses.Itishypothesizedthatstudentsinthisrange
haveinadequateneuralactivationtosupportsustainedperformanceandconsequentlymay
misssalientcuesinthecontexttosupportongoingresponsivity.Jasonmayappear
uninterestedandnotparticipatefullyinclassroomactivities.

Seeking
:
Scoresintheprobable/definitedifferencerangerepresentstudentswhotendtobe
activeandcontinuouslyengagedintheirenvironments.Theyaddsensoryinputtoevery

experienceindailylife.Jasonmaymakenoiseswhileworking,fidget,ruborexploreobjects
withtheirskin,chewonthingsandwrapbodypartsaroundfurnitureorpeopleaswaysto
increaseinputduringtasks.Hemayappearexcitableorlackconsiderationforsafetywhen
playing.

Avoiding
:
Scoresintheprobable/definitedifferencerangerepresentstudentswhomayengage
inverydisruptivebehaviorshypotheticallybecausemeetingthresholdsoccurstoooften,which
isuncomfortableforthestudent.Inordertokeepthestimulationatbay,theyavoiditbyeither
withdrawingorengaginginemotionaloutburststhatenablethemtogetoutofthesituation.
Fromabehavioralstandpoint,Jasonmightseemstubbornorcontrolling.Hefunctionsbestwith
ritualsandtendtocreatethemfortheirdailylives.Jasoniscreatingasituationtolimitsensory
inputtothoseeventsthatarefamiliarandthereforeeasyforthenervoussystemtointerpret.

SchoolFactorScoreExplanation

SchoolFactorScoresreflecttheteachersperspectiveaboutthestudentwithinthecontextof
theclassroom,learningactivitiesandtheschoolday.Scoresreflectthewaysthatstudents
mightlearnorhavebarrierstolearning.EachSchoolFactorScorecontainstwosensory
processingpatterns.

SchoolFactor1:
Representsthestudentsneedforexternalsupports.ItencompassesSeeking
andRegistrationpatterns.Jasonmayneedalotofextrasensoryinputtoactivatetheirhigh
thresholdsinordertobepreparedforlearning.Hewilllikelyneedsupportswithinthelearning
environmenttoparticipatesuccessfully.

SchoolFactor2:
Representsthestudentsawarenessandattentionwithinthelearning
environment.ItincludesSeekingandSensitivitypatterns.Jasonwilllikelyneedadjustments
withinthelearningenvironmentsotheycanparticipatesuccessfully.

SchoolFactor3:
Representsthestudentsrangeoftoleranceforsensoryinput.Itincludes
AvoidingandSensitivitypatterns.Jasonmaygetoverloadedquicklyinthetypicallearning
environments,interferingwithhisabilitytogetinstructions,completeindependentworkor
cooperatewithotherstudentsingroups.Jasonmaybeseenaslesstolerant,overlyreactive
andpicky.Hewillneedreductionsinstimuliwithinthelearningenvironmentsotheycan
participatesuccessfully.

SUMMARY

RECOMMENDATIONS
TheTEAMwillneedtoconsidertheseresultsofthisevaluationalongwithotherevaluationsto
determinewhateducationalprogramandplacementwouldbestmeetJasonseducational
needs.Thefollowingrecommendationsaddresstheresultsofthecurrenttesting:

1.
Jasonmaybenefitfrompreferentialseatingclosetoinstruction.
2.

FurtherrecommendationswillbediscussedattheTEAMmeeting.Itwasapleasuretowork
withJason.Ifthereareanycommentsorconcernspleasefeelfreetocontactme.

Sincerely,

_____________________________________________

ArmandGonzales
Date