Hunter was referred for an occupational therapy evaluation as part of a reevaluation for special education eligibility due to difficulty

with
organizational skills, poor in-class participation, and difficulty with written
expression tasks. The focus of the evaluation was the development of an
occupational profile -- what Hunter sees as meaningful tasks, what are
expected tasks, and current and historical performance of those tasks. The
occupational therapist gathered information using the Child Occupational
Self Assessment (COSA). Based on Hunters responses on the COSA, the
occupational therapist also used the Adolescent/Adult Sensory Profile, the
AIR Self-Determination Scale, and the Casey Life Skills Education High
School Self Assessment. In addition to the standardized assessments, the
occupational therapist also used skilled observation, parent and teacher
report, and a review of records to complete the evaluation.
Hunter is a 17-year-old adolescent 10th grader who enjoys thinking about
science problems, cooking meals, and taking care of members of his family.
He does not currently have any medical diagnosis but reports a suspected
traumatic brain injury as a child. Hunter lives with his grandparents and
spends the weekends with his mother. He has half-siblings whom he did
not meet until recently. Hunter and his mother report that he is
independent with all basic ADLs, he is able to cook meals independently,
and he is able to use public transportation independently to access
shopping and recreational activities in his community. Hunter attends an
alternative high school due to difficulties he experienced when he attended
his boundary school. Hunter reported that the number of people at the
comprehensive high school was overwhelming. He would get angry just
walking down the hallways and that he was suspended for going into a
rage last year. Hunter reports that he struggles to complete schoolwork
and values taking care of his grandparents and working after graduating
from high school.
His teachers report that Hunter struggles to complete work and does not
engage with peers in the classroom. For example, in cooking class,
although he enjoys cooking, Hunter was observed to disengage from
working with the other three students in his group, sit down in his assigned
seat away from the kitchen, and put his head down. When the teacher
attempted to redirect Hunter back to the kitchen, he refused to engage in
conversation with her. Hunter has not received occupational therapy
before this evaluation. He has received special education services primarily
in the areas of communication, reading, writing, math, and
social/emotional or behavior.

The occupational therapist gathered information using the COSA about

Hunters preferred activities, how he perceives his strengths and
weaknesses, and how he rates the importance of these general skills in his
life. Performance scores are reported as: I have a big problem with this, I
have a little problem with this, I do ok with this, and I am really good at
doing this. Value scores are reported as: Not important, important, really
important, and most important. Hunter rated himself as I am really good
at doing this or I do this ok 23/25 items. He identified 2/25 items as I
have a little problem doing this. Hunter did not rate himself I have a big
problem doing this for any item. Hunter identified 6/25 items as being
not really important or important to me. Of the 19 other items, Hunter
identified 11 as being really important to me and 8 as most important of
all to me. Hunter identified feeling both a higher level of competency and
rated these activities as having a higher value:
Keep my body clean.
Dress myself.
Eat my meals without any help.
Get my chores done.
Get enough sleep.
Have enough time to do things I like.
Get around from one place to another
Choose things that I want to do
Do things with my family.
Do things with my friends.
Finish my work in class on time.
Get my homework done.
Calm myself down when I am upset.
Hunter rated himself as having lower competency for a higher valued
activity on 3 items:
Keep my mind on what I am doing.
Follow classroom rules.
Make others understand my ideas.
Hunter rated himself as having lower competency along with feeling that
the activity is less valued on 3 items:
Ask my teacher questions when I need to.
Think of ways to do things when I have a problem.

 Keep working on something even when it gets hard.

Hunter reported that this is the first year that he feels that he fits into a
school and has friends. He is beginning to invite the friends over to his
house to play video games and hang out after school. Hunter reported
that he shuts down and not engage when he struggles in class and
identifies this as how he does not follow classroom rules. He reports not
asking his teachers questions because he struggles to remember what his
question was by the time he crosses the room or gets called on. Hunter also
reports that he struggles to make others understand his ideas. He forgets
what he was going to say in conversations. Hunter reports struggles with
written expression. He reports thinking that he has written one thing but
when people proof read his work Hunter realizes he had skipped words or
has incomplete ideas.
These ratings indicate that there are many occupations that Hunter feels
that he does poorly but values highly, resulting in dissatisfaction. This may
lead to changes in roles or habits, resulting in worse performance or
participation. Hunter is at risk for decreasing performance due to
dissatisfaction with his performance or decreasing the value of occupations
to align with his perceived competency.
The occupational therapist administered the Adolescent/Adult Sensory
Profile after reviewing the COSA results with Hunter and due to his report
of going into a rage by entering certain environments. Scores calculated
for a 95% confidence interval are as follows:
Low registration 39-56 (raw score 47)
Sensation seeking 33-51 (raw score 42)
Sensory sensitivity 21-39 (raw score 30)
Sensation avoiding 33-49 (raw score 41)
The range of scores for all areas overlap the similar to most people rating.
Two areas scores, low registration and sensation avoiding, overlap from the
higher end of similar to most people into the lower end of much more
than most people. This indicates that these scores are most likely in the
more than most people range. However, Hunter only indicated 3 items
out of 15 in the sensation avoiding area as being frequent or almost
always. This indicates that he is most likely functioning in the similar to
most people range in general for sensory avoiding but may avoid specific
events due to other reasons (i.e. social discomfort, memory issues).

Hunters scores indicate that he has lower sensory registration than most
people and he rated 7 out of 15 items as frequently or almost always.
Items that Hunter rated as frequently or always less sensitive to include:
I trip or bump into things.
I miss the street, building, or room signs when trying to go
somewhere new.
I get scrapes and bruises but dont remember how I got them.
I dont seem to notice when someone touches my arm or back.
It takes me more time than other people to wake up in the morning.
I dont notice when my name is called.
Several of these opportunities naturally occur in traditional high school
classrooms, which may affect Hunters performance. When a student has
low sensory registration, he may miss important cues in the environment.
Noticing pertinent information on a chalkboard/white board, alerting to
cues to pay attention (e.g. when someone calls his name or touches his arm
to gain his attention) and concentrating for a 50-minute period without
missing important auditory or visual information are all skills affected by
Hunters self-reported lower sensory registration.
The Casey - Education High School Assessment was used to understand
Hunters perspective on those skills he does not feel he has mastered. It
also provides insight into how supportive he perceives the adults in his life
are to his educational needs. Hunter responded mostly yes and yes to
the following percentage of items in:
Goals 60%
School Environment 93%
Home/Community 100%
Study and Technology 86%
Basic Skills 66%
Motivation and Participation 66%
Relationships 85%
Hunter reports that he knows which classes he needs to take to graduate, he
can name at least one career that interests him, and he can identify an adult
who will support him in achieving his goals. He reports that his school is a
safe and friendly place, he feels treated with respect at school, and that the
counselors at his school seem to care about him. Hunter identified that he

has good skills in using technology, including using e-mail, word

processors, keyboarding, and keeping his information safe and private
online. Finally, Hunter reports wanting to continue his education after
high school, following school rules, and has a strong desire to finish high
school.
Some of the skills Hunter reported mostly no or no include:
I know how to apply to the college I might want to attend.
I have had a summer job or a part-time job during the school year.
When I miss a class, I ask a friend or teacher what I missed.
I am capable of following directions.
I read for pleasure at least once a week.
I can write a business letter.
I never have unexcused absences.
I regularly participate in at least one extracurricular activity at least 2
or 3 times a month.
I have held a leadership position at school.
Hunter reported lower levels of competency in the areas of forming and
achieving goals, basic school skills, and motivation and participation.
Several of these self-identified deficits align with the results received from
the COSA.
Finally, Hunter completed the AIR, a self-determination scale. Hunter
reported high levels of competency in self-determination. His overall
report was at 93%. He reported moderate competency in his capacity to do
things, especially planning and adjusting plans, and in how he feels.
Hunter reported high competency in the opportunities available to him,
especially with planning and adjusting the plans.
Some of the areas Hunter reported lower competency include:
Sometimes set goals to get what he wants to needs.
Sometimes figure out how to meet his goals.
Almost never begin working on his plans to meet his goals as soon
as possible.
Almost never begin working on his plans right away.
Sometimes check on how well hes doing meeting his goals.
Sometimes at school hes learned how to make plans to meet his
goals and feel good about them.

 Sometimes at home, people encourage him to start working on his

plans right away.
Typically developing students in high school have learned skills that
support organization of both classwork, homework, and daily self-care
activities. They independently ask for help with school work and are able to
socially interact to complete group projects. As students transition to high
school and begin to prepare for adult occupations, they develop effective
problem solving, are able to make long term goals and plans to fulfill those
goals, persist when meaningful activities are challenging, and are beginning
to make decisions and choices that affect the quality of their life.
Hunter currently reports struggling with self-advocacy, problem solving,
and planning. He reports reduced motivation to get his work completed.
Hunters difficulty with planning and problem solving negatively affect his
ability to perform written expression work despite access to assistive
technology such as word predictors and text to voice software programs. At
the end of the first semester of this school year, Hunter had 63 missing
assignments, indicating that he is not meeting his goal of successfully
completing school.
Based on the assessment results and observations, Hunter demonstrates
difficulties with performance with a number of expected activities. Hunter
reports reduced performance and satisfaction with several occupations as
well. He especially struggles with self-advocacy, self-determination,
planning, and organization to complete work independently.
Due to his difficulty with problem solving, organization, and self-advocacy,
Hunter requires occupational therapy as a related service in order to benefit
from specially designed instruction in social/emotional skills and written
expression skills. Occupational therapy services will support Hunter by
helping him learn how to establish daily routines to work towards long term
goals and review his efficacy towards meeting those goals. Finally,
occupational therapy services will support Hunters development of selfregulation skills and increase the rate at which he learns to respond
appropriately to challenge, develop self-direction, and self-advocacy skills.