OCCUPATIONAL THERAPY EVALUATION
NAME: Simone Harter DATE: 1/23/06
DOB: 7/23/01 THERAPIST: Elsa Leonard, M.S., OTR/L
AGE AT EVALUATION: 4 yrs. 6 mos. TEACHERS: Kathy Major, Ada Brett, Leslie Core
BACKGROUND INFORMATION: Simone is a delightful 4 ½ year old girl who likes looking at books, listening to music and helping with chores at home. She lives with her parents and 8 year old brother, Jacob, in Sometown, N.C. Simone was born at term following an uncomplicated pregnancy. She has demonstrated delays in all areas of development and has had extensive testing, including MRI, EEG and genetic testing, the results of which have been normal. Simone previously attended Bright Horizons Family Enrichment Center, and has been attending Child’s Play Child Care Program since the fall of 2005. Her current diagnoses are developmental delay and apraxia of speech.
METHODS: Family and teacher concerns were identified using an adapted form of the Canadian Occupational Performance Measure in November of 2005. Observation, direct interactions and the Knox Preschool Play scale were used to assess Simone’s current level of functioning in self-care and play activities.
CLIENT/FAMILY CONCERNS
Simone’s family would like for her to become more independent in:
Toileting
Dressing
TEACHER CONCERNS
Toileting
Dressing
Mealtime routines (using spoon consistently)
Play: outdoors, pretend play, constructive play, computer play
OCCUPATIONAL PERFORMANCE ISSUES
Occupational Performance Areas:
§ Activities of Daily Living: Simone feeds herself at home, but needs reminders at school to use a spoon at meals. Simone will sit on the toilet when taken by adult, but does not always void into the toilet, and can “hold it” for relatively long periods of time. She does not let adults know that she needs to use the toilet. Simone is able to take off all clothing, and has demonstrated the ability to put on pants, socks and slip-on type shoes. However, her performance of dressing tasks is inconsistent, and she tends to take a somewhat passive role in dressing by being cooperative but allowing others to dress her.
§ Play: Simone plays in a variety of areas of the classroom, and is beginning to participate in more structured group activities, such as art/creative activities and circle time, by imitating models provided by peers and adults. She enjoys looking at books, sensory play, and exploratory play with blocks and other manipulatives. However, she plays only briefly in most types of play, and needs moderate to maximal support from adults to expand her play and to complete play activities. Simone watches peers at the computer, but doesn’t interact with the computer on her own. Pretend play is very limited, though imitative skills are developing, and she is starting to do dress-up activities when preferred peers are present. Outdoors Simone likes playing in the sandbox and riding trikes. She will carry a ball around, but needs adult support to engage in simple games (e.g., catch) with the ball. In many activities, Simone needs repeated direction to attend visually to the actual activity, as she is often interested in looking at the people in her environment. Through observation, it was also noted that Simone’s basic manipulative (fine motor) skills are adequate for the types of play that she is doing, and tool use skills are emerging.
Test Scores:
Knox Preschool Play Scale (KPPS): The KPPS allows the examiner to both observe the child in play and to play with the child in attempts to elicit more diverse or sophisticated play behaviors. Another adult or child can also be used to support the child in higher levels of play during observation. Play behaviors are categorized as space management (gross motor play), material management (constructive and manipulative play), pretend/symbolic play, and overall participation in play activities. The tool can be used with children from birth to age 6; age levels are divided at 6 month interval through age 3 years, and then in 12 month intervals.
Results for Simone:
o Space Management (active play using primarily gross motor skills): Skills approximate those of a 24-month old child
o Material Management: Skills solidly representative of play typical of an 18-month old child, with emerging play skills noted in the 18-24 and 24-30 month ranges.
o Pretense/Symbolic -Imitation: Skills representative of play typical for an18 month old child
o Pretense/Symbolic- Dramatization: Skills representative of play typical for an 18 month old child
SUMMARY: Simone demonstrates the ability to manage most dressing tasks on her own, and to use the toilet when taken. However, because she tends to take a somewhat passive role in self-care tasks, she needs to perform basic dressing and toileting tasks more independently, including letting others know when she needs to use the potty. Simone’s current play preferences include primarily exploratory and sensory-based play, though she is beginning to use imitation to try new play activities. Her interest in and understanding of more complex play behaviors such as building with assembly toys, coloring and drawing, pretend play, computer games and interactive outdoor games needs to be fostered. With increased interest in and understanding of these types of play, her attention and effort can be focused to support skill development in constructive play, tool use, and pretend play.
RECOMMENDATIONS:
1. Occupational therapy consultation to classroom teachers, other team members, and family to
o develop strategies that increase understanding of and interest in more complex types of play
o assist in developing frequent opportunities for engagement in new types of play in order to expand her play repertoire
o develop strategies that support increased independence in self-care tasks
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Elsa Leonard, M.S., OTR/L
Occupational Therapist