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ST.

URIEL’S THERAPY CLINIC
Door 2 Dr. Teresita Santos Apartments, Kalayaan, City of San Fernando Pampanga

 ( 0916) 6951901 Email: st.ur ielsther apyclinic@gmail.com

Name: Kyle Evaluation Date: September 16, 2011 Date of Birth: July 1, 2008 Chronologic Age: 3 years and 2 months

Occupational Therapy Initial Evaluation
REASON FOR REFERRAL
Child was referred to St. Uriel Therapy Clinic by his neurodevelopmental pediatrician, Ma. Paz Irene P. Lucido-Bautista, MD.,DPPS,FPSDBP. He has a diagnosis of Autism Spectrum Disorder. Primary reasons for referral to occupational therapy include poor eye contact, no turning to name calling, poor sitting and attending skills, self help skills, fine motor skills and to decrease hyperactivity. Kyle is the adopted son of Antonio and Nilda Mojica. His father is a retired employee and his mother works in the office. He has a 22 year old sister, a 19 year old brother and a grandmother that also lives with them. Kyle spends most of the time with his nanny. He takes Phenobarbital for his seizures.

FORMAL AND INFORMAL ASSESSMENTS ADMINISTERED
Short Sensory Profile Pediatric Evaluation of Disability Inventory Parents Interview

BEHAVIOR DURING ASSESSMENT
Kyle has fleeting eye contact and do not respond when his name is called. He is distracted to the things around him and touches everything he sees. There are also times that he would lie on the floor and on the table when activities are presented. He needs verbal prodding and physical prompting to look at the objects presented. Kyle indicates needs most of the time by pointing and cries when his needs are not met.

Performance Components Fine Motor Performance. Child needed positional prompting to stack rings and put wood insets. lumpy. Social Skills. He points the object he wants and cries if need is not met. Clinical observations show normal muscle tone and range of motion. Gross Motor Performance. Sensory Processing. can perform scooping using a spoon and bring it to his mouth. He use gestures to communicate needs.ASSESSMENT RESULT Performance Areas Functional areas at home. Based on the mothers interview Kyle can use spoon to eat but with maximal spillage and cooperates in dressing by raising his arms and legs to put them in the sleeves. Therapist was not able test Gross Motor skill because of child’s low attention and alertness level. cut up. When presented cubes to stack he just banged them together. Auditory Filtering. Underresponsive and Seeks Sensation is on Probable Difference while Tactile Sensitivity is on Definite Difference. Posture and gait also appeared normal. Neuromuscular status. hold a cup. Movement Sensitivity. Using the HELP checklist he completed some of the items in the 12-18 months level. chunky and diced foods. SECTION Tactile Sensitivity Taste and Smell Sensitivity Movement Sensitivity Underresponsive and Seeks Sensation Auditory Filtering Low Energy and Weak Visual and Auditory Sensitivity TOTAL SECTION RAW SCORE TOTAL 21/35 16/20 14/15 22/35 26/30 27/30 19/25 145 Definite Difference Typical Performance Typical Performance Probable Difference Typical Performance Typical Performance Typical Performance Probable Difference . Low Energy and Weak and Visual/Auditory Sensitivity Sections. Placing one round peg needed no assistance and prodding. Based on the Short Sensory Profile filled up by his mother Kyle showed Typical Performance Taste and Smell. Using the PEDI form filled up by his mother it also showed that he is capable of the following skills: eating of ground. opens mouth when brushing and turn on and off water and obtains soap when washing hands.

Consult with parents. OTRP . 3. 2.RECOMMENDATIONS Based on initial assessment the following recommendations are suggested: 1. caregivers and teachers regarding strategies for improving language. Consult with caregivers regarding self help and behavior management at home. Introduce a task schedule to promote structure and transition of tasks. Noted by _______________________ Occupational Therapist Julie Anne Pensotes. 4. Direct occupational therapy to provide regular sensory stimulations in his sensory diet to improve level of attention and alertness.

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