You are on page 1of 6

Evaluation Report

Elizabeth Clinch
Utica College

OCCUPATIONAL THERAPY EVALUATION REPORT


CHILD INFORMATION

Name: Sierra
DOB: 9/8/09
Date of Evaluation: 9/25/16
Age: 7
Grade: 2nd
School: W.A. Wettel Elementary

INTRODUCTION
The focus of this occupational therapy evaluation was to address Sierras challenges as well as
strengths in terms of her occupational performance, in order to determine whether or not she
would benefit from skilled occupational therapy services. The evaluation included an interview
with both Sierra, her mother, and grandmother to gather information to form her occupational
profile. All aspects of this evaluation were conducted in Sierras home to observe her interacting
with her belongings and family within her natural environment. Administration of one
occupation based assessment, the Occupational Performance Assessment for Children (OPAC),
and one skills assessment, the Goal-Oriented Assessment of Lifeskills (GOAL), were conducted
to gather information so that a comprehensive picture of Sierras occupational performance could
be formed.
OCCUPATIONAL PROFILE
Sierra was born at a local hospital in upstate NY with no health concerns. The single health
condition that she now has is seasonal allergies, which she takes medication for. If she does not
take her medication her symptoms at times bother her enough that she does not participate in
outdoor activities. According to Sierras grandmother, she has found that Sierra has met
developmental milestones without any concerns. At 7 years old Sierra is the youngest of three
children. Sierra and her mother recently moved into her grandmothers home with her
grandfather, uncle, and her 2 siblings. Since growing up in another city with her mother Sierra
was not provided with the most stable, and consistent living environment. This has impacted her
in several ways, according to her grandmother. It caused her to become more independent at an
earlier age than her other siblings. Although, because of this she says that Sierra is very outgoing
and has a matter of fact personality. It has also provided difficulties with following directions, a
routine schedule, and sharing with her siblings since these factors were sparsely provided when
living alone with her mother.

3
In addition, Sierra is a talkative and bubbly child who says that playing games on her iPad,
swimming, playing with her Barbies, going to school, and playing with her brother, sister,
family, and friends are among her favorite hobbies. Her daily routine tends to be quite busy and
productive since her move. At school, she has received several certificates of outstanding
performance, called the Starfish Award. She states that she enjoys going to school; math, art,
and music are her favorite subjects, but struggles sometimes with spelling since she mixes up bs
and ds. Sierra says that she gets her self-dressed in the morning but her grandmother sets out
her outfits for her. She enjoys eating a healthy variety of foods but spaghetti, and burgers are
among her favorites.
Her familys main priorities of focus for Sierra are to address her ability to follow directions and
stay focused on the task at hand, since she often gets off track due to her curiosity, which can get
her into trouble at home and at school. They would also like more resources and advice on how
to provide a more stable living environment for Sierra as well as her 2 siblings.
RESULTS
During administration of the two assessment tools it was observed that Sierra has healthy social
emotional interactions with her family members. Although, at times did not follow directions
well due to becoming distracted, and playing with her new Barbie. She moved fluidly through
her home getting off and on a stool to eat dinner. Before beginning the assessment, she was able
to independently utilize the bathroom without her familys assistance or direction. While at the
kitchen table she ate a full dinner with her meat cut for her, she successfully used her utensils.
There was no indication from my observation or through the interview that she had any issues
with visual function or perception. Her living environment was observed to be quite involved
with many different family members including her mother, grandmother, grandfather, uncle, and
2 siblings residing in the same house hold. Due to the high capacity in their house hold it was
observed that there were many belongings around the home but, this did not seem the effect her
since she could maneuver without any noticeable concerns.
Sierra was happy to discuss questions asked on the occupation-based assessment, the OPAC,
stating that she loves her classrooms sea theme, its pretty blue walls, and the fact that she is
able to sit close to her friends. She likes that her teacher is nice, that she cares about the
students, and she helps them a lot. Her favorite thing about school is math and her classroom.
One thing she dislikes is that she has to get everything right, that challenges her. Stretch leader
is one of the duties she has within her class room, which entails picking a stretch to do with her
class on a brain break, which provides a much-needed break from school work. In addition to
math she also favors art and music class, expressing that she would like to become an art or
music teacher someday. One are that presents a challenge is spelling, since she often gets her bs
and ds mixed up. Sierras mother shared that often times she hands her homework in earlier
than most students. She says that her teacher has a few rules which are to follow directions
quickly and to make her teacher happy by being well behaved. In her classroom, if the rules are
not followed their clips are moved to a different color, (blue=best, yellow, green, orange,
red=worst and the teacher talks to parents), most of the time she is on blue. Sierra enjoys quiet
on the bus, it makes her upset when kids are yelling and talking loudly. Eating lunch, playing on

4
the playground are among her favorite activities during her school day. There are about six
students, both girls and boys, that she considers to be her friends. She likes them because they
are friendly, nice, and they help her out. She also likes that they play together and that they show
her cool things. If she could change anything about her school, she would add bouncy houses for
all the students, some would even get their own personal bouncy house. She would also like to
make her classroom bigger to fit more fun things inside.
The skills-based assessment tool, the GOAL, scores fine motor and gross motor areas. Sierra
scored a 1+ SD which is above average when compared to children of the same age. Her overall
functional ability GOAL Progress Score was a 571 which on average places her between the 1011-year-old range in terms of fine motor and gross motor skill function. This was consistent with
my observations of Sierras fine motor skills such as planning, sequencing, bilateral coordination
during utensil usage. Visual-motor skills, alignment, and stability were challenged during
opening locks. The only activity that she did not pass was opening a combination lock. Other
skills observed were spatial organization, hand precision, endurance, tactile, proprioception, and
alignment during constructing a paper box. Organizing a binder with sheets of colored paper
focused on stability, spatial organization, ideation, and visual motor skills. She surpassed all
basic steps and scored mainly in the bonus step areas resulting in a raw score of 23, translating to
a standard score of 145, placing her in the <99.9th percentile for fine motor skills. Gross motor
skills were addressed during dressing, ball play and carrying a tray. They included balance,
weight shift, temporal organization, planning, sequencing, full body accuracy, visual,
proprioception and vestibular input. The sum of all passed steps for gross motor was a raw score
of 17 which translated into a standard score of 126, placing her in the 96th percentile. Two steps
were marked as unexpected areas; one resulted in an unexpected success for the cutting step
where she scored outside of the expected category for her scores. The other was an unexpected
failure for the dribbling step where she scored lower than expected.

Goal-Oriented Assessment of Lifeskills (GOAL)


Ages

Average Progress Scores

Sierra (Current age 7 years old)


7 years old
8 years old
9 years old
10 years old
11 years old
12-13 years old
14-17 years old

Sierras Standard Scores


Standard Deviation = 15
Mean Score = 100

571
~ 480
~ 510
~ 530
~ 560
~ 590
~ 600
~ 640
Fine Motor
145

Gross Motor
126

OCCUPATIONAL ANALYSIS
Information gathered from both assessments throughout this evaluation have been used to
determine the childs overall occupational performance. Scores and responses have shown that
Sierra is in line with her occupational and physical performance skills when compared to other
children her age. With that being said, there are a few barriers that Sierra is faced with and they
include; a slight decrease in gross motor skill function when compared to fine motor skill
function. There was a 19-point difference between the fine motor and gross motor scores with is
a significant difference in function. This may impact her during gross motor activities and thus
impact her occupational performance. A challenge was observed during ball play section of the
GOAL. The dribbling step of this section was the most difficult for Sierra, categorized as an
unexpected failure. Client factors that were challenged here were proprioception, vision,
balance, feedforward, temporal organization, full body accuracy, unilateral preference, and
endurance. I believe Sierra had trouble with this section since she was becoming taxed with the
length of the assessment and also because it was getting late in the evening by this time. A fine
motor area in which she struggled slightly with was constructing the paper box, in particular
having the dexterity and bilateral coordination to attach tape to form the sides completely. Even
though it was stated not to rush while completing all steps, I believe this was the factor in this
specific case while forming the paper box. All other areas Sierra performed well above average
with no concerns in function.
Sierra demonstrated a variety of performance skills throughout the two assessments. On the
OPAC she approached the task at hand requiring verbal prompts to pay attention to the questions
of the assessment. It was easy for her to get off track and start playing with her Barbie. I noticed
that she at times, did not make eye contact during both assessments but did interact appropriately
with objects and others which supports her occupational performance. This observation may be
due to her level of concentration needed to complete the GOAL, as well as becoming distracted
with her Barbie. Her grandmother shared that the performance patterns demonstrated during the
dressing, undressing, utensil usage, tray carrying steps are consistent with her performance
during her daily routine.
At times her home environment, where she took both assessments was some what distracting as
her siblings and family members were all present at different times throughout. A few times her
sister came and sat next to her which was distracting for Sierra, no steps were attempted during
this time to eliminate the chance for inaccurate scores. I can see how this physical environment
could be challenging to complete homework or to even have privacy at times since she shares a
room with her sister, and mother. At the same time, living with many of her family members
presents an increase in her social support network when compared to her previously living
situation. Sierra seems to enjoy her current living arrangements, causing no concern at this time.
The activity demands addressed by these assessments showed that Sierra works well in her
natural living environment, and a quite space as she expressed in the OPAC. She understood and
followed the sequencing of the activities and was able to perform them in a timely manner.
When the directions of the assessments were read to her she understood them and followed them

6
in the correct order. She was able to use the necessary tools to complete all activities. These
aspects are vital since they directly impact her ability to perform her daily occupations at home,
and at school.

RECOMMENDATIONS
At this time, Sierra does not meet the criteria needed to receive occupational therapy services due
to her score on the GOAL (1+ SD above average). Although, Sierra would benefit from at home
activities that can address gross motor skills such as bilateral coordination of her LE in order to
improve her balance, hand eye coordination, weight shift, proprioception, endurance and full
body accuracy during her desired daily activities. Since she enjoys swimming and has a pool at
home, the family could implement different gross motor pool activities to improve these factors.
Establishing a daily schedule and routine which has implements chores, play and time to
complete homework in a quite area, would provide consistency in Sierras daily life. Using a
visual daily schedule placed on the refrigerator would assist her throughout her daily routine.
Her family may consult the occupational therapy department if Sierra declines in any areas of
development which impact her performance in daily activities whether at home or at school.
SIGNATURE

Elizabeth Clinch, OTS


Occupational Therapy Student