OCCUPATIONAL THERAPY INITIAL EVALUATION

Name of Client LUCIDO, Vince Joel

Nickname Vince
Age/Sex 1 10/12 years old / Male
Date of Birth 4 April 2017
Medical Diagnosis -
Referring MD -
Primary Informant Mrs. Lucido (mother)
Date of Referral -
Date of Initial Evaluation 19 February 2019

I. Occupational Profile

CHIEF COMPLAINT GOALS

“Minsan pag tinatawag, hindi lumilingon.” [improve work behaviors to be able to follow
commands]
“Di pa nagsasalita. More on no and hindi lang
sinasabi. Maingay pero di naiintindihan sinasabi.”

DOCTOR’S ORDERS PRECAUTIONS

A. History of Present Condition, Developmental, Education/Intervention History

There were no remarkable events noted before and after pregnancy. However, mother reported that she
acquired edema and experienced high blood pressure nearing birth. Vince was born to a then 39-year
old mother via caesarian delivery. He is an only child
 Delays in Vince’s development were noticed when he was around a year old. As reported by his mother,
he would be exposed to the television for almost the whole day. They observed his limited speech and
poor response to name calling.

The said observations were reported to his pediatrician, Dr. Pamintuan. The doctor recommended to wait
for further observations before referring to a neurodevelopmental pediatrician since Vince is too young.
His mother decided that Vince should receive occupational therapy services while waiting for an
appointment to a neurodevelopmental pediatrician. This is Vince’s first time to receive occupational
therapy services.

B. Contexts
1. Home
Vince’s lives with his mother, grandmother and ate. He is mostly left with his grandmother or ate
since his mother works at their store. His father is a soldier and is currently based in Tawi-Tawi. He
goes home around 3-4 times a year.

Vince’s routine at home is generally unstructured. It is comprised mostly of self-care tasks such as
feeding, bathing, etc. as well as play activities. He likes playing with cars, fruits and vegetables, and
animals. When playing with toys, he would usually hold them in pairs and puts them repeatedly. He
was also observed to bang them on surfaces that make sound. The use of gadgets has been greatly
decreased. He only listens to nursery rhymes using a radio.

2. School
Vince currently does not attend any form of schooling. Additionally, it is still not expected for his age.

C. Performance in Areas of Occupation, Activity Demand and Performance Patterns

*AI – age appropriate; AA – age appropriate (Grades were based on the Brigance Developmental Inventory)

OCCUPATION GRADE EXPECTED OF AGE PERFORMANCE/DESCRIPTION

Eating/Feeding AI • Takes spoon from Vince is spoonfed by caregivers during said

plate to mouth, with task. According to his mother, he refuses to
some spillage hold a spoon when given one. He also does
• Sucks from straw not engage in finger feeding. He prefers the
• Drinks from cup or food to be put on his mouth by the
glass held in one
hand without caregiver. He is still assisted when drinking
assistance from a cup.

There were no noted problems in terms of

food repertoire.

Dressing AI • Removes socks Vince is able to cooperate during dressing

• Assists in undressing tasks. However, he is unable to manage
• Assists in dressing fasteners such as large zippers.
• Unzips non-
separating front
zipper
 Toileting AA • Indicates wet or Vince wears a diaper all throughout the
soiled pants day. He is able to indicated that he pooped
by poking the caregiver.

Bathing AA • Cooperates in drying Vince is cooperative during bathing.

hands
• Cooperates in
washing hands
Grooming/Hygiene AI • Willingly allows nose Vince refuses during grooming tasks such
to be wiped as haircutting and brushing teeth.

Play AI • Engages in play in Vince’s level of play is mainly in the

which he pretends to sensorimotor stage. This can be observed
sleep or eat through banging his toys on the table or
• Imitates other surfaces that may produce sound.
environmental
However, limited exploration of toys was
sounds during play
• Imitates in play an observed.
activity involving
housework
• Imitates motion of an
object
Social Participation AI • Shows a strong Vince exhibits (+) separation anxiety and
sense of self as an (+) stranger anxiety. He usually does not
individual as respond to commands given by both
evidenced by saying familiar and unfamiliar people. There was
no to an adult’s
no imitation of actions noted or reported by
request
• Imitates another mother.
child’s actions
• Watches the faces of
other people for
clues to their
emotions or feelings

II. Barriers to occupational performance

A. Body-mind structures and functions required to perform occupations
o Neuromusculoskeletal and movement-related functions
All aspects in this area remain unremarkable except for muscle tone. Vince was observed to
be hypotonic when assessed through touch. Range of motion of all joints are within functional
limits. Muscle endurance were within functional limits.

o Sensory processing functions

To determine Vince’s ability to process sensory information in daily activities, he was observed
inside the clinic during play. Additionally, information about his sensory processing was
obtained from an interview with his mother.

There was no standardized assessment tool administered due to resource constraints.

Functional assessment was conducted to note observations on his sensory processing.
 Based on observations in the clinic and reports from his mother, Vince may have vestibular
discrimination difficulties. This was observed when he was perturbed forward as well as
sideways while standing. He was noted to have delayed arm extension to protect himself from
falling.

In terms of the tactile system, he may exhibit tactile over responsiveness to certain textures.
As observed, he was apprehensive when touching slimy textures such as glue and clay, but
can tolerate rough textures such as sand. This is also reported through avoiding activities such
as haircutting.

In terms of the auditory system, he may also exhibit auditory over responsiveness. He was
reported by his mother to cry when hearing loud noises such as fireworks and changes in
volume of voice.

In terms of the proprioceptive system, Vince seems to show proprioceptive under

responsiveness. This may coincide with reports that he seems to be “lazy” whenever tasked
to perform activities. He was also observed to be sluggish during movement tasks, often taking
a longer time in moving his extremities through an obstacle.

With this, Vince should be provided with play activities that would facilitate organization of his
systems. This will be done through exposing him to different sensory experiences during
therapy sessions. Addressing these sensory processing difficulties will assist him in his
occupational performance.

B. Skills and learned behaviors required to perform occupations

o Gross motor skills
*AI – age appropriate; AA – age appropriate (Grades were based on the Brigance Developmental Inventory)
GROSS MOTOR SKILL GRADE REMARKS
Walking AA Unremarkable
Running AA Unremarkable
Jumping AI Vince was noted to need maximal physical assistance in jumping.
He was observed to be unable to assume position in jumping (knees
bent, crouched position)
Balance Beam AA Unremarkable
Rolling and Throwing AI Vince needed physical assistance in rolling a ball while in seated
position as well as hurling a ball presented.

o Fine motor skills

*G – good, F- fair, P- poor

GRADE REMARKS

RGCR F Upon evaluation, Vince was noted to have difficulty in releasing toys when
transferring. He had difficulty with performing voluntary release.
Grip strength F Vince was observed to release grasp on squigz after a few seconds when
attempting to remove them from the glass surface.
Pinch strength P He was observed to have difficulty in obtaining small animal pieces from
theraputty.
 GROSS PREHENSION PATTERNS
Cylindrical G Vince was able to assume, maintain and use cylindrical grasp in holding a
bottle.
Hook G Vince was able to assume, maintain and use hook grasp in holding the basket
handle to carry it.
Spherical G Vince was able to assume, maintain and use spherical grasp in getting balls.
FINE PREHENSION PATTERNS
Lateral Vince was able to assume a lateral pinch in getting formboard pieces but
F noted difficulty in maintaining and using it.
Pad-to-pad Vince was able to assume a pad-to-pad pinch in getting formboard pieces
but noted difficulty in maintaining and using it.
Tip-to-tip P Vince needed hand-over-hand assistance in transferring small pegs using a
tip-to-tip pinch
Three jaw chuck P Vince needed physical assistance to assume, maintain and use a three jaw
chuck grasp in opening clothespins.
WRITING SKILLS
Pencil grasp AA Palmar supinate
Hand preference Left
IN-HAND MANIPULATION
Finger-to-palm F Vince was able to get coins from the table and transfer it to his hand with
translation some instances of dropping noted.
COORDINATION
Eye-hand F He is able to shoot shapes inside wooden peg shape sorter but with
coordination occasional difficulty in putting the hole towards the wooden peg.
Arm-hand G He is able to shoot rings and stack them independently with no undershooting
coordination or overshooting noted.
BILATERAL COORDINATION
Symmetrical G No noted difficulty in pushing the basket presented to him.
Asymmetrical F Physical assistance was needed for him to stabilize the fruit using one hand,
as he slices with the other
Reciprocal F Vince showed some difficulty in coordinating his hands and feet with
alternating movements such as when climbing up the stairs of the slide

o Visual perceptual and visual-motor integration skills

Vince showed functional visual perceptual skills as he was able to obtain his preferred toys
among others in the clinic. However, he was unable to perform more complex visual perceptual
skills such as matching and sorting.

o Listening skills
Vince was observed to have poor auditory processing skills as reported with his poor response
to name calling. Additionally, no response was noted when he was verbally instructed to give
and put back the toy presented to him.

o Communication skills
Vince’s expressive language skills are limited to one-word utterances such as “no” and “hindi”
only. Other verbalizations are rarely noted. In terms of receptive language skills, he was
observed to be unable to follow commands such as “sit down”, “stand up”, and “high five”.
 o Cognitive skills
Vince has limited knowledge of concepts in such as colors and shapes. However, he is able
to use ADL objects that he uses regularly.

o Work behaviors
*G – good, F- fair, P- poor
WORK BEHAVIOR GRADE REMARKS
Attention Span P Vince exhibited poor attention span lasting for ~1 minutes during
non-preferred task such as matching a formboard piece and around
~2 minutes for preferred tasks such as letting him play with a toy of
his choosing.
Concentration P Vince has poor concentration as he is easily distracted with visual
and auditory stimuli around the environment such as the presence
of several toys in the mat area and other sounds such as a kid crying.
Impulse Control F Vince showed fair impulse control, with instances of grabbing toys
on his immediate vicinity. This may be typical of his age.
Frustration Tolerance P Vince showed poor frustration tolerance often crying or disengaging
from a task that he cannot perform.
Sitting Span F Vince requires physical prompts to remain seated on chair during
table-top activities. This may be typical of his age.
Following instructions P Poor compliance was noted during the evaluation session as he was
noted to have (+) stranger anxiety.

III. Analysis of the transaction between factors: performance (functions and skills), roles, routines,
and environment

AREAS WITH DIFFICULTY OCCUPATIONS AFFECTED

Sensory processing Difficulty in regulating sensory needs result in
disruption of self-care activities such as
haircutting as well as overall occupational
performance
Work behaviors Difficulty in concentration, sustained attention,
frustration tolerance and following instructions
may affect Vince’s ability to participate in all his
areas of occupation such as play. He may have
difficulty finishing tasks that are too difficult for
him or even shift from one activity to another,
later on affecting independence in his
occupations.
Fine motor skills Difficulty with using fine prehension patterns
such as a three-jaw chuck and tip-to-tip pinch
may affect his ability to manipulate small toys as
well as fasten buttons and zippers during self-
care tasks.
Visual perceptual skills Problems in visual perceptual skills will affect
learning new concepts such as colors, shapes,
etc. This may also hinder development of skills
related to school participation.
Listening skills
Social-communication skills
Difficulty in active listening will affect almost all of
Vince’s occupation due to problems in
processing verbal instructions.
Difficulty with expressive language will affect all
of Vince’s occupations. He will be unable to
express his needs to his parents and will later on
affect social interaction with other children.

Difficulty with receptive language will affect

Vince’s ability to follow verbal commands and
learning new concepts.
Self-care skills Difficulty doing self-care tasks will affect self-
efficiency. Not being able to engage in these
tasks without assistance will also require
caregiver’s presence whenever he is needed and
may result in disruption of routine of caregiver
and caregiver burden.

IV. Plan

SKILLS THAT AFFECT OCCUPATIONAL TARGET OUTCOMES

PERFORMANCE
Sensory processing o Tolerate hand-over-hand assistance within
5-10 seconds
o Tolerate certain textures such as glue, slime
and clay
o Tolerate changes in posture such as when
being bounced on vestiball
Work behaviors o Attend to atleast a 5-minute activity
o Continue engaging with activities even when
experiencing difficulty
o Tolerate maximal physical assistance during
structured activities

Fine motor skills o Remove squigz independently without

Visual perceptual skills
Listening skills
release of grasp
o Assume, maintain and use tip-to-tip pinch
given moderate physical assistance
o Assume, maintain and use three jaw chuck
pinch given moderate physical assistance
o Match colors independently such as when
putting circles on pegs
o Match shapes independently such as when
presented with a shape sorter
o Perform 1 step verbal command given visual
cues
o Perform 1 step verbal command without
repetition
 Social-communication skills o Eliminate crying when being handed over to
therapist during session
o Initiate play by choosing a toy he prefers
o Imitate actions with a toy during play
Self-care skills o Remove socks independently
o Remove velco closure of shoes
independently
o Tolerate holding spoon during feeding

Recommendations:

For the family

o Encourage Vince to be independent in his self-care tasks. This can be done through gradually
decreasing the assistance given to him during dressing, feeding, etc.
o Enforce consistent behavior management strategies at home across all people.
o Remove or limit the use of gadgets during the weekends only.
o Facilitate language development through the use of language stimulation techniques. This can
be done through narrating what Vince’s actions are as he is doing it.

Report prepared by:

Nina Karmela V. Garcia, OTRP
Occupational Therapy Consultant
PRC License No. 003537


Should you have any question regarding this document, do not hesitate to contact
the undersigned at mobile number 0917 829 2985 or e-mail at
nkvgarcia@gmail.com.