Appendix I

Patient name: M. Smith

DOB: 7/1/2000 Age: 16 yrs. 3 mos.
Dx code:
Tx code:
Account code:
Initial OT Evaluation
To Provider From Provider Patient

D. Douglas, MD Jeannie Poole, OTR/L M. Smith

Address: Address: K. Smith (mom)
Phone: Phone: Address:
Fax: Fax: Phone:
Insurance:
Number:

Date: Name: M. Smith

9/19/2016 Age: 16 years, 3 months
Parents names: K. Smith
Referring provider: D. Douglas, MD
Fax:
School:
Strengths and interests: M. is calm, conversant, and appropriate during todays evaluation. He attended to all
activities and completed to the best of his ability. He states that he enjoys art/drawing, listening to music, and has
2-6 close male friends who he enjoys camping and going to the lake with in the summer and hangs out with
during the school year at his/their homes.

Current Services: M.s mother states they are initiating multiple services in the next couple weeks, including
occupational therapy, counseling, physical therapy, psychologist, and closer consultation with the school district.

Siblings: M. is the oldest of seven children. The youngest child in the home is 6.

Medical History: Extensive medical history with multiple diagnoses of Aspergers Disorder (ASD), ADHD,
Tourettes Syndrome, and Anxiety. He has received occupational therapy services in the past, but it has been greater
than 5 years ago. He has a current IEP at his school district to ensure appropriate adaptations to his work and school
day.

Developmental History- M. was born full-term, vacuum-assisted delivery, and experienced no complications after
birth. His mother states she did have toxemia during pregnancy. He achieved all developmental milestones in the
first three years of life on time or early, with the exception of a mild speech delay. His mother reports extreme
temper tantrums during his early years, which continue as anger outbursts currently.

Educational and Therapy History: His mother reports that M. has experienced severe difficulty with school and
particularly during high school years. She is concerned that he is not achieving the basic learning and skills needed
 to transition in two years to independent living after high school. She is very unhappy with services that have
historically been provided at public school. So, this year they are trying homeschool/online school, re-initiating
multiple therapies, and participation in a technical program to teach him vocational skills. He has received
occupational, speech and physical therapy services in the past, but none in the past 5 years.

Chief Parent concerns

Complaint The caregiver is asking for support so M. can behave appropriately in social situations, for example, coping
strategies that Marcus can use independently when overwhelmed by sensory stimulation or social demands
in his environment without adult intervention. She is also requesting support so Marcus can complete basic
and instrumental activities of daily living independently with few to none verbal reminders from his mom.
His mother also states she would like assistance with preparing M. for transition from school to community,
including preparation for employment, independent living, and community integration.

What participation looks like now in the home environment

Right now, when M. is in a family environment he is easily overwhelmed by siblings and his home
environment which can lead to altercations with other families. He often isolates himself and prefers being
alone in his room to listen to music. He requires frequent-constant verbal reminders for basic ADLs and
self-care routine and schedule from his mother. If not prompted by verbal reminders, M. will neglect
showering, changing clothing, homework, etc. Mother says that these challenges make it difficult for M. to
build independence in self-care and educational demands at home. Mother reports that it can be difficult for
M. to participate in activities because he struggles with managing his moods and physical/emotional
response to negative stimuli, and is often aggressive in the home environment.
Structured Primary Underlying Deficits include:
Clinical
Observations Under responsive systems (takes a lot of input to register): vestibular (movement sense), proprioceptive
&Assessment sense (muscle sense of position and force) creating a need for excessive movement in order for M. to feel body
in space.
Over- responsive systems (very little input will feel like too much) : tactile (touch) and auditory impacting
ability to participate in community settings and self-care
Fluctuating over and under responsive to visual input
Retained primitive reflexes including a significant and indicating immature nervous system and impacts
ability to manipulate objects with correct force and coordination due to the overflow of movement from one
body part to the other (e.g. neck to arms).
Weakness: delayed core strength
Coordination Delays: poor ability to demonstrate smooth controlled movements.

Observations:

Sensory: M. can be easily overwhelmed by sensory experiences especially in the areas of auditory, touch and
body position. By recognizing these difference when participating in social situations and playing with other
children we can support him and his family.

Medical PATIENT is at risk for injury:

Necessity 1) Due to inability to follow warnings, poor attention and memory
2) During social interactions due to sensory sensitivities and anxiety
3) For injury during gross motor and fine motor activities due to low tone, delayed core strength for
movements against gravity also impacting ability to focus (has to put energy into think about the body to
maintain posture), and involuntary wrist movements.

PATIENT has delayed development for motor and social skills milestones:

1) Inability to sit with good body alignment to participate in fine motor tasks due to poor core strength and
decreased body awareness.
2) Socially inappropriate sensory seeking (e.g. chews on collars and shirt sleeves, rocks unconsciously in
chair, causes self-harm by frequently forming hickies on his arms)
3) Limited higher level motor skills due to poor ideation and motor planning
4) Inability to follow directions and complete tasks due to poor attention and sequencing, including self-
cares.
5) Requires assistance with self-care skills (e.g. tooth brushing, showering, clothing changes) due to tactile
hypersensitivity and decreased awareness of body odor/poor hygiene.
6) Inability to calmly participate and cooperate with peers/siblings due to sensory overload and poor social
skills
7) Socially inappropriate behaviors to ordinary sensory stimuli (e.g. overacts to loud and crowded
environments and demands from siblings)
8) Very picky eater (will not eat more than 10 items, prefers sugary foods) due to over responsive tactile oral
sensory system

Observations WNL NT IMP

Finger to nose with eyes closed (proprioception and kinesthesia)

X
 Schilders Arm Test (body disassociation)
X

Sequential Finger Touching (finger individuation, eyes closed proprioception and kinesthesia)
X

Slow Ramp (proprioception, kinesthesia, graded muscle control)

X

Jumping Jacks (Bilateral integration, vestibular system)

X

Skip (Bilateral integration, vestibular system) V

X

Antigravity Flexion:yr/sec 4/10, 5/21, 6/37, 7/57, 8/104 (tactile/ proprioception and core strength)
X

Antigravity Extension yr/sec 4/18, 6/29, 8/30 (vestibular system and core strength)
X

ATNR (body disassociation)

X

Protective Extension (body disassociation)

X

Weight Bearing and proximal joint stability on UE (core strength, graded muscle control, prop )
X

Gravitational Insecurity (vestibular system)

X

Postural Control (vestibular system and core strength)

X

Moving, object and Moving body (visual motor integration, spatial awareness, postural control)
X

Conscious Eye movements (vestibular system and strength of eye muscles)

X

Automatic Eye Movements (vestibular system)

X

Diadokokonesis rapid alternating movements of forearms (proprioception and kinesthesia)

X
 Stereognosis ID object by feel (tactile, proprioception and kinesthesia)
X

Oral Motor (tactile proprioception, motor planning)

X

Praxis ( motor planning, ideation)

X

Tactile Play (tactile)

X

Writing Grasp (tactile, pressure modulation finger individuation, strength, proprioception, motor planning)
X

Standard Sensory Profile:

Scores An assessment of PATIENT's sensory processing patterns at home by asking HIS/HER caregiver to complete the Child Sensory
Profile 2. This assessment is a questionnaire for ages 3:0 to 14:11 years in which the caregiver marks how frequently he/she
engages in the behaviors listed on the form.

PATIENT responds to some sensory experiences just like the majority of his/her peers in response to visual stimuli, response to
movement, and response to items in or around the mouth.
PATIENT is just like her peers in his/her ability to manage her attention.
Factor Raw Score Typical Performance Classification
Sensory Seeking 44 8563 Definite difference
Emotionally Reactive 8057 Definite difference
44

Low Endurance/Tone 4539 Probable difference

38

Oral Sensitivity 4533

24 Definite difference

Inattention/Distractibility 3525
17 Definite difference

Poor Registration 4033

19 Definite difference

Sensory Sensitivity 2016

17 Typical performance

Sedentary 2012
6 Definite difference

Fine Motor/Perceptual 1510

9 Probable difference

Sensory Processing
Auditory Processing 4030
19 Definite difference
Visual Processing 4532
28 Probable difference

Vestibular Processing 5548

31 Definite difference

Touch Processing 9073

44 Definite difference

Multi sensory Processing 3527

26 Probable difference

Oral Sensory Processing 6046

36 Definite difference

Modulation
Sensory Processing related to Endurance/Tone 4539
28 Definite difference

Modulation Related to Body Position and Movement 5041

32 Definite difference

Modulation of Movement Affecting Activity Level 3523

15 Definite difference

Modulation of Sensory Input Affecting Emotional 2016

Responses 13 Definite difference

Modulation of Visual Input Affecting Emotional Responses 2015

and Activity Level 10 Definite difference

Behavior and Emotional Responses

Emotional/Social Responses 8563
49 Definite difference

Behavioral Outcomes of Sensory Processing 3022

13 Definite difference

Items Indicating Thresholds for Response 1512

9 Definite difference
Standard Beery-Buktenica Developmental Test of Visual-Motor Integration (VMI)
Scores VMI: Raw Score: 28
Percentile: 50th %,
Range: average
Standard Deviation: 0.00
Visual Perceptual Subtest: Raw Score: 22
Percentile: 4th %
Range: Low Average, Borderline
Standard Deviation: -1.8
Motor Coordination Subtest: Raw Score: 18
Percentile: >1st %
Range: Low
Standard Deviation: -3.15

Summary: Standardized testing scores were significant for Sensory Processing Disorder/Sensory
Integration Dysfunction and for Motor (Fine Motor) Coordination.
Due to safety concerns and developmental delay Marcus requires Occupational Therapy.
POC Frequency and Duration: up to 2x week for 12 months.

Treatment Plan: Occupational Therapy is recommended up to 2x per week for up to 12 months in home,
community and/or clinic. Skilled OT intervention may include but is not limited to the following: therapeutic
exercise, therapeutic activity, neuromuscular- re-education, manual therapy, cognitive skills, community skills, and
self-care to address treatment goals.
1) Parent education and home program because parent lacks information on how to help their child with self
-regulation of the central nervous system (e.g preventing fight/flight/freeze/shut down response).
2) Skilled OT intervention: Therapeutic activity for fine motor, social, and neuromuscular re-education for
balance and core strengthening
3) Recommendations to increase body awareness and calmness: Home Program including sensory strategies
4) Comprehensive evaluation including convergence/divergence, saccades, eye alignment

This patient has good potential to progress and achieve the following functional goals through continued OT
treatment and compliance with a home program; parents are very motivated to help their child:

Safety: At risk for injury (falls, unsafe or socially inappropriate sensory seeking, unsafe perception of pain, unsafe
orally (items in mouth), inability to follow warnings, poor attention and memory poor ability to respond
appropriately and safely under normal everyday stressful situations. During social and family interactions Marcus
lacks strategies for self-regulation which result in physical and verbal aggression.
Proprioception: Treatment will include push/pull/carry/resist, build obstacle course, bouncing, spandex, joint
compressions to improve core strength and body awareness.
Kinesthesia/ Vestibular System: Treatment may include rotary, vertical, angular, vibration input to improve
vestibular sensory processing.
Tactile: Therapeutic approaches including brushing, multiple textures, desensitization to improve tactile sensory
processing.
Visual Perception/Visual Motor Integration: Treatment to include copy near and far models shapes and
letters/numbers.
Fine Motor: Treatment to include Handwriting Without Tears, grasp strengthening, pinch strengthening, finger
isolation, thumb strengthening, web space/intrinsic strengthening, in-hand manipulation skills, pressure
modulation.
Gross Motor Balance: Treatment to include bilateral integration/crossing midline, body dissociation, and
strengthening (core, UE stabilization).
Self-Care: Treatment to address grooming/hygiene, dressing, sleeping, and routine establishment.
Social Skills: Treatment to include training book, peer activities, flexibility, shut down, strategies to decrease
aggression /outbursts, cope with everyday stress, frustration tolerance, personal space, tolerating community
environments (family gatherings restaurant,, store, movie, parks).
Cognitive: Attention activities, organizational skills, memory activities, picture schedule
Goals Short Term goals within 3 months
1. Home program implementation 5/7 days per week for 3 weeks
2. Demonstrates impulse control by following safety rules at OT clinic in order to be at less risk for injury
80% on 4/5 trials
3. No falls with a rapid equilibrium reaction on play equipment in order to be at less risk for injury 80% on
4/5 trials
4. Able to follow multiple step directions with picture/written schedule as needed to increase attention and
sequencing 80% on 4/5 trials
5. Only put designated safe and socially appropriate items in mouth (eg. Gum, pencil chew) for 3 weeks
6. No loss of balance on moving play equipment in order to be at less risk for injury on 4/5 trials.
7. Marcus needs to participate in activities in/at: various public environments and home and/or
friends/relatives homes without fight/flight/freeze response 100% of the time

Long Term Goals- within 6-12 months

1. Respond to therapist commands, warnings, multiple step directions in clinic in order to be at less risk for
injury and to be able to complete tasks 80% on 4/5 trials
2. Physical endurance increased to 30-45 min of gross motor play 80% on 4/5 trials
3. Able to demonstrate core strength within normal limits (trunk for 5 minutes increased from one
minute) in order to be less risk for injury 80% on 5 trials
4. No aggressive or verbal outbursts in OT clinic, at home and in community 80% on 4/5 trials
5. Able to sit with good body positioning for 15-30 min during fine motor/handwriting exercises 80% on 4/5
trials
6. Able to participate cooperatively with peers/adults in multi-step dramatic play and/or follow simple game
rules 80% on 4/5 trials
7. Demonstrates flexibility with activity choice with adults and peers 80% on 4/5 trials
8. Participates well at meal time, willing to try 2 new foods per week and maintain variety in diet for 1 month
9. Interact with peers and adults without and without fight/flight/freeze/shut down response in order to
reduce risk for injury in the community 80% of 4/5 trials
10. Able to demonstrate activities he can do to stay in the blue zone when starting to feel angry 80% on 4/5
trials
11. Able to independently ask for break/implement coping strategy prior to escalation in the clinic 80% on
4/5 trials
12. Able to identify triggers and initiate self-regulation strategies in home and community 80% on 4/5 trials
13. Able to complete self-care tasks without verbal reminders from mom and with adaptive techniques (e.g.
visual/written schedules) 6/7 days per week
14. Able to engage in fine motor tasks for 30 minutes 4/5x at clinic and > 45 minutes at home without fatigue
15. Able to complete 3/5 transitional objectives for school to community transition to include areas of work
goals/part-time job, postsecondary/technical training, self-advocacy, organizational and study skills, self-
care/IADLs, and community participation (shopping, checking account, bus use, etc.).
Therapist Jeannie Poole, OTR/L

Therapist Signature______________________________________Date:________________________________

Doctor For Physician Use Only

I concur with the above recommendation. Other__________________________________________

Name of Doctor:

Doctor Signature_________________________________________Date:_________________________________