Executive Function Occupational Therapy Assessment

Name: Grade:

DOB/Age: / Date:

General Observations

□ Able to wait outside door to room quietly □ Enters room and explores/runs around the room
□ Unable to wait quietly- frequently interrupting others □ Transitions away from activities without difficulty
□ Enters room and go straight to chair □ Difficulties transitioning between activities during assessment

Activity Brief Description Skills Comments/Notes Age Norms

Motor This item was designed
Observation to assess a child’s ability
Skills to use his or her hands to
Assessment hold an object as well as
use in a controlled
(Legos / manner for precise finger
Craft) and hand movements
during writing and
cutting activities.
Children were required
to organize space and
objects in order to plan a
series of directions in a
logical and efficient
order, select correct
materials and ignore
incorrect materials, as
well as monitor progress
for proceeding to next
task. Children were
required to monitor their
time to complete project.
Grasp Patterns Organization Grasp Patterns
___ No concerns (functional ___ Difficulty with open- 3-4 yrs children switch to static
_____grasp) ended assignments that tripod or quadruped grasp. By 5
___Other require brainstorming years should see dynamic grasp.
or choosing a
Scissors Skills theme/topic Scissor Skills
___No concerns ___ Approach to work is 5-6 yrs children use mature scissor
___Inefficient grasp logical, efficient, and grasp consistently and progress
___Uncoordinated organized from cutting out simple to complex
___Leaves workspace neat / shapes and figures smoothly.
Writing puts away tools and
___ Spacing and sizing errors materials Writing
___ Difficulty lining up answers on ___ Approach to work is 1St - 2nd grade: correct letters/
worksheets inefficient and numbers formation; places letters/
___ Copying difficulties disorganized; appears numbers 1/16th above or below
___Rushes through assignments to not have a plan baseline; uses appropriate spaces
without reading directions or ___ Leaves workspace a 3rd grade: print text at 45 wrds/min
checking work mess 4th grade: print text at 60 wrds/min
5th grade: print text at 70 wrds/min
Manipulation Self-Awareness / Time
___ Difficulties w/ markers Management (HWT Standards for Writing)
___ Difficulties w/ glue ___Ask for help when stuck
___ Difficulties w/ paper in folders ___Needs prompting to get Attention
unstuck or generate A normal attention span is 3 to 5
Initiation ideas minutes per year of a child's age.
___ Waits to last minute to start ___Shows some beginning By age 5 children need at least a
___ Appears unsure where to ability to monitor time 25-minute attention span to
start for completing tasks perform adequately in school.
Activities of This item was designed
Daily Living to assess a child’s ability
Skills to recall a series of steps
/ plan for frequently
(Complete occurring activities, apply
morning, knowledge to select
evening correct materials, and
routine / organize in a logical and
Make a efficient order for
sandwich) completion within a
reasonable time frame.
Motor This item was designed
Planning to assess a child’s ability
and Sensory to follow multi-step
Processing directions as well as
Assessment initiate, plan, and
execute a series of motor
(Simon Says actions. This item
/ Repeat required the child to
and maintain an appropriate
Remember) arousal level matching
the social expectation of
the environment and
activity in order to
sustain performance
throughout task. The
child was required to
demonstrate active
listening skills and
appropriate personal
space while listening and
remembering a series of
verbal directions.
Planning
___Lists steps correctly
___Unable to recall correct steps
/ Omits steps in plan
___Lists inappropriate use of
space and objects or lists in
inappropriate order for time
management and efficiency
Arousal Level
___High ___Just right ___Low
___Seems to talk excessively
___Likes to make loud noises
___Has difficulty matching
arousal level to environment
Touch
___Seems overly sensitive to
other kids bumping into
___Constantly touching things
___Bumps into peers frequently
during transitions
___Seems unaware of personal
space
Sensory
___Waits turn appropriately
___Difficulty waiting turn
(fidgets, makes noises,
etc.)
___ Difficulty filtering out
extraneous stimuli in
environment and
sustaining focus
Attention
___Maintains focus on the
required task
___Easily Distracted
(___visual ___auditory)
Motor Planning
___ follows 2+ step
directions
___unable to follow 2+ step
directions
___movements appeared
smooth and efficient
___movements were
clumsy / ungraded
___unable to maintain body
position with upright
rotation in standing
___Difficulty coordinating
both sides of the body
Regulation
___upset easily (everything
is a big deal)
___expresses emotions
appropriately
Age 4-5
Get dressed with minimal parental
help / Make their bed with minimal
parental help / Bring their things
from the car to the house /Be
responsible for a pet's food and
water bowl
Age 6-7
 Make their bed every day /Brush
teeth / Comb hair / Choose the
day's outfit and get dressed / Put
their laundry in their drawers and
closets

Age 8-11
 Take care of personal hygiene /
Keep bedroom clean / Be
responsible for homework / Be
responsible for belongings
Arousal Level
2nd grade: bring materials to and
from school: homework
assignments; permission slips;
lunch money; complete homework
assignments (20 minute
maximum); run errands (2-3 step
directions)
3rd-4th grade: Run errands that may
require a time delay (e.g.
remembering to do something
after school); perform chores that
take 15-30 minutes
Finger to Nose
Measured on children 5+
5+: touch within 1cm of nose
7+: does not miss more than once
Motor Planning
Most 3 yr olds have no trouble
following a two-part direction.
Summary

Concerns with:

□ Tool Use / Grasp Patterns □ Motor Planning

□ Writing o Body Awareness
□ Sensory o Initiation
o Arousal Level o Planning
o Flexibility o Execution
o Impulse Control o Multiple step directions
o Sustain Attention o Problem Solving
o Modulation (__auditory ___visual ___tactile)

Are impacting ability to participate in: _________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________

Plan

□ Initiate weekly OT services for 16 weeks upon which point in time OT services will be re-evaluated for ongoing needed for weekly services.
□ Continue OT services with focus on
o Developing sensory and emotional self-regulation o Developing strategies for sustain attention and persist with
o Strengthening self-awareness skills for promoting self-regulation activities of daily living
throughout activities of daily living o Teaching strategies for improving organization of materials for
o Developing strategies for impulse control efficient use of time
o Strengthening self-awareness skills for problem solving abilities
□ OT services are not recommended at this point in time.