Kaleidoscope Therapy & Learning Center
Occupational Therapy Initial Evaluation
Zone 1 Brgy. Palanas Lemery Batangas
T (043)740 2175 M:09988658050,09175081870, 09164003859
E kaleidoscopetherapycenter@yahoo.com.ph
W www.kaleidoscopetherapyandlearningcenter.com
DATE:
DEMOGRAPHIC DATA:
Name:
CALVIN KYRIE HOLGADO
Age
2 years and 5 months
Date of
Birth
February 24, 2014
Gender
Male
Diagnosis
Language delay
Address
Autism Spectrum Disorder
Suspect
Date of
Doctors
Assessme
nt
July 18, 2016
Ref MD
Edna V. Gonzaga, M.D., DPPS
Reason for
IE
To train on social skills and
self-help skills
Fathers
Name
Occupation
Mothers
name
Occupation
OT in
charge
For behavior management
program
Ms. Mariella C. Vargas, OTRP
Schedule
Friday 1:00-2:00
Saturday 2:00-3:00
BACKGROUND INFORMATION
Chief Complaint: According to his mother, Hindi pa siya nakakapagsalita. Nagwawala siya kapag hindi
nasusunod ang gusto.
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OT Initial Evaluation 2016
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Birth Hx
Prenatal
This was the mothers first pregnancy and first child. Not until the 5th month of conception the mother
did realized her pregnancy. Subsequently, she got regular check-ups and took vitamins. The mother
also encountered two minor accidents obtaining minimal bruises but without causing vaginal
bleeding. Maternal infection such as UTI was also noted.
Perinatal
Kyrie was born at full term with a weight of ___lb., to a then ___y/o G1P1 (F1P0A0L1) mother via
caesarian section delivery. No significant complication during delivery.
Postnatal
The patient was discharged quickly from the hospital without any jaundice but had later
hospitalization for 3 days with convulsion. A complete vaccination was noted
Social
Informa
tion
Primary
Caregiver
Housing
Bungalow type with 2 rooms and 2
comfort rooms
Primary Language
Tagalong/ English
Family
Living with his family including his
mother and auntie. No available playmate
of his age.
School
N/A
Behavior Observation
Comments
Self Stimulating
Lining up of toys
Relates to : People/Object
Able to do eye contact with people
and objects
Respond to certain stimulations
from the environment
Motivated
Motivated with toys
Fearful
Separation and stranger anxiety
Difficulty transitioning as to
environment and persons
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OT Initial Evaluation
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Kaleidoscope Therapy & Learning Center
Birth Hx
Prenatal
This was the mothers first pregnancy and first child. Not until the 5th month of conception the mother
did realized her pregnancy. Subsequently, she got regular check-ups and took vitamins. The mother
also encountered two minor accidents obtaining minimal bruises but without causing vaginal
bleeding. Maternal infection such as UTI was also noted.
Perinatal
Kyrie was born at full term with a weight of ___lb., to a then ___y/o G1P1 (F1P0A0L1) mother via
caesarian section delivery. No significant complication during delivery.
Exhibits safety awareness
Need further assessment
Easily distracted
Needs further assessment
Low frustration tolerance
Needs further assessment
Exhibits ability to problem solve
Not yet observed
Exhibits body awareness
Not yet observed
ANALYSIS OF OCCUPATIONAL PERFORMANCE
ASSESSMENT OF CLIENT FACTORS
PLAY/ WORK BEHAVIOR
-
He was able to follow and comply to some common and simple commands as to verbal and gestural with
moderate to minimal signs of hesitations and/or fear.
He was able to remain seated and wait for more than 15 minutes during on and off tasks.
He was observed to have fair impulse control as he tried to grab some toys presented to him.
Initiating a task was noted to be difficult for him depending on the familiarity of the task. He has fair attention
span but was able to finish a series of adult directed activities for around 5-10 minutes given prompts.
He was able to attend to the task and resist minimal to moderate amount of distractions.
In approaching simple activity, he appeared to be organized when instructed what to do and was able to pack
away the toys after the instruction.
As reported by his mother, he usually becomes frustrated whenever not given with things he wants and often
tends to throw tantrums.
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SOCIAL-EMOTIONAL SKILLS
-
Kyrie was initially demonstrated crying behavior due to separation and stranger anxiety causing him not to
cooperate with the task. Eventually, as he was able to somehow regulate his emotion he was able to interact
and respond to the demand of the activity provided with physical and verbal prompts.
He demonstrated meaningful eye contact and has high consistency in responding to name calling.
He needs verbal and physical prompts to initiate and respond to interaction such as saying and gesturing hi
and goodbye etc.
Pointing and sharing of interest, emotion and affect were observed but reduced to some extent causing him to
have difficulty in this area of connecting to other people.
Difficulty of using verbal and non-verbal communicative behaviors was significantly noted.
Transitioning from different environment, persons and activities was a challenge for him due to difficulty with
adaptations.
VISUAL-PERCEPTUAL AND COGNITIVE SKILLS
Kyrie was able to match and finish form board puzzles given moderate cues and prompts.
He requires moderate assistance to sort toy bears according to colors (e.g. blue and yellow).
He was able to understand some simple command such as sit, stand, get, put, shoot with some gestural and
visual cues.
As to imitation, he showed difficulty with imitating movements and sounds due to delayed motor planning,
and sequencing
Difficulty with problem solving was observed as he was not able to fit in a puzzle piece in the board without
realizing he needs to rotate it.
Some knowledge on how to use common everyday objects was noted such as the spoon, cups, plates, fork, face
towels etc.
Difficulty in recognizing letters, numbers and common objects/pictures was noted.
Limited body awareness
FINE MOTOR SKILLS
Kyrie was able to manipulate common task objects appropriately.
He was able to hold and nest the cups one at a time.
He was able to stack a block at the top of another in a steady manner.
He can bring spoon to mouth and drink from a cup.
GROSS MOTOR SKILLS
He can walk up and downstairs with alternating feet with minimal assistance
He can walk and balance on a beam with one hand support but he tends to lose his balance when the
assistance was removed.
Symmetrical and asymmetrical integration of both sides of the body were considerably at par of his age as he
was able to perform gross motor activities.
PERFORMANCE IN AREAS OF OCCUPATION
Activities of Daily Living
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OT Initial Evaluation
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Feeding/ Eating
-
Kyrie us able to indicate or express whenever he wants to eat and drink by gesturing and/or pointing. He can
do finger-feeding, and drink from a cup.
He is sometime spoon feed and when he eats by himself he tends to get untidy due to spillage.
Dressing
-
Kyrie is able to cooperate with donning and doffing his clothes, socks and shoes.
Toileting
-
Not yet fully toilet trained.
OVERALL ASSESSMENT
Based from the clinical observation and assessment of the clients factors, Kyrie has difficulty in play, social
participation and ADL due to problems in working and play behaviors, social-emotional skills, sensory processing
skills, fine and gross motor skills and cognitive skills.
INTERVENTION PLAN
1.
To improve work behaviors necessary to support participation in play and ADL, Kyrie will:
a. Be oriented to different house rules such as that follows:
i. Listen
ii. Follow
iii. Sit nicely and wait
iv. Quiet mouth, hands and feet
v. Tap or ask teacher
vi. Use of visual support or icons to familiarize with the instructions
b. Complete/ finish one task before proceeding to another
c. Use kind firmness and modulated tone of voice when instructing him.
d. Refocus on task after getting distracted given 2-3 verbal prompts.
2.
To improve visual-perceptual and cognitive skills necessary to facilitate participation in ADL, play and social
activities, Kyrie will:
a. Form board puzzle with different concepts such as letters, numbers, fruits and shapes
b. Matching, sorting and recognizing colors, shapes, letters, numbers and common objects
c. Pointing and naming body parts to increase awareness
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d.
e.
Imitation simple actions and sounds.
Using flashcards of different concepts
3.
To improve fine motor skills necessary to support ADL, play and social participation, Kyrie will:
a. Manipulate snapping toys, surprise eggs, connecting toys, nuts and bolts etc.
b. Fixing puzzles with the components of turning, rotating and flipping the pieces of puzzle
c.
Stringing large and small beads
d. Shooting chips into the coinslot
e. Lacing boards
f. ADL boards (buttoning, zipping and connecting buckles)
g. Clay activities (cutting, rolling and poking)
4.
To improve gross motor skills, Kyrie will participate in the following activities:
a. Jumping on the trampoline
b. Going through the tires and tunnel
c. Wheelbarrow walk
d. Balancing on the beam and board
e. Climbing up and down the wall climber and stairs
f. Sliding down the slide pulling and pushing activities
5.
To improve play and social participation, Kyrie will:
a. Appropriately respond to familiar adults affect including facial expression, gestures, tone, request,
comments or corrections given moderate prompting
b. Engage in pretend and symbolic kind of play
c. Follow the childs interest with some adult intrusion while providing language stimulations
d. Participate into small group activity
6.
To increase participation in ADL/ Self-care, Kyrie will:
a. Remain seated during mealtime
b. Coordinated use of spoon and fork during feeding to minimize spillage
c. Indicate toilet needs by gestural and verbal means
d. Pulling down and up of lower body garment when toileting
e. Wash hands after toileting
f. Tolerate hair cutting and nail trimming
g. Donning and doffing of clothes, socks and shoes
h. Manipulating ADL boards (buttons, zipper, buckles, etc.)
7.
Parent Education:
Parents and family members will be educated with the proper use of behavior modification
techniques and language facilitation strategies. It is important to carry out the intervention program at home
and to other settings. Minimize the use of gadgets and TV is highly recommended but in case to be provided
make sure to supervise him. Avoid giving him food with high content of artificial sugar, preservatives and
additives. Provide a more structure environmental set-up at home.
RECOMMENDATION
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Kaleidoscope Therapy & Learning Center
Kyrie is recommended to attend 2x a week individual OT intervention to manage the following concerns:
work behaviors, sensory processing, visual-perceptual skills, fine and gross motor skills, social interaction and ADL
skills.
For any suggestions, questions and comments regarding Kyriess report. Please feel free to contact the undersigned
therapist.
Assessed & Prepared by:
_________________________________
Mariella C. Vargas, OTRP
PRC Lic #: 0002970
Kaleidoscope Therapy & Learning Center
Noted by:
___________________________
Monaliza Guce, OTR/L, OTRP
KTLC Center Director
OT Initial Evaluation
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