Occupational Therapy Report

Clinician Specialty: Occupational Therapist Occupational Therapy Report Referral Reason: The referral for occupational therapy was initiated due to parental concerns regarding 7-year-old Leo's difficulties with fine motor tasks, particularly handwriting, and noticeable clumsiness during play activities. Leo also carries a diagnosis of Attention-Deficit/Hyperactivity Disorder (ADHD), predominantly inattentive presentation, which parents feel may impact his motor skill development and participation in daily tasks. Background Information/Developmental History: Leo was born at term after a 39-week pregnancy, weighing 7 pounds 2 ounces. His early developmental milestones were generally met within typical ranges, though parents recall some delays in independent dressing and using cutlery. His gross motor development progressed as expected, with walking achieved at 13 months. However, concerns regarding coordination and balance emerged around age 4, notably during playground activities where he struggled to keep up with peers. There is no significant family history of motor development delays or learning difficulties. Leo has not received any prior input from other professionals specifically for motor function, though he is currently managed by a paediatrician for his ADHD. School Information: Leo is currently in Year 3 at Willow Creek Primary School, taught by Mrs. Eleanor Vance. Mrs. Vance has observed that Leo struggles to maintain legible handwriting during extended writing tasks, often leading to incomplete assignments. He also demonstrates difficulties with cutting accurately and managing fasteners on his clothing during school hours. Socially, Leo is well-liked by his peers but sometimes withdraws from active play dueances to perceived physical limitations. Movement ABC-3: Movement ABC-3 assessment results indicate that Leo scored within the 5th percentile for his age, with a standard score of 75, suggesting significant motor coordination difficulties. Specific areas of strengths and difficulty identified on Movement ABC-3 are as follows: Manual Dexterity: Leo demonstrated particular difficulties with tasks requiring precise manipulation, such as threading beads and drawing shapes. His performance on these tasks placed him below the 3rd percentile, indicating notable challenges in fine motor control and dexterity. He exhibited slow and deliberate movements, often requiring multiple attempts to complete tasks accurately. Aiming and Catching: During aiming and catching tasks, Leo's performance was within the 10th percentile. He struggled with anticipating the trajectory of objects and exhibited delayed reactions, leading to frequent misses when catching a beanbag. His throwing accuracy was also inconsistent, often missing targets by a significant margin. Balance and Locomotion: Leo's balance and locomotion skills were within the 8th percentile. He displayed unsteady balance during single-leg standing and struggled with dynamic balance tasks such as hopping on one foot. His gait during running appeared somewhat uncoordinated, and he frequently stumbled over his own feet during obstacle courses. Parents reported occasional trips and falls at home, supporting these observations. Non-motor factors reported by parents include Leo's perceived low self-efficacy in physical activities and a tendency to avoid tasks requiring fine motor precision, such as drawing or building with small blocks. They also noted occasional frustration and meltdowns when faced with motor challenges, possibly exacerbated by his ADHD. Clinical Observations: Leo presented as an engaged and cooperative child with a good sense of humour. Observed sensory differences included a heightened sensitivity to certain textures, particularly rough fabrics, and occasional fidgeting. He demonstrated some motor planning and coordination difficulties, particularly when asked to sequence unfamiliar movements. His personal strengths include his imaginative play and strong verbal communication skills. Fine motor skill observations revealed a poor pencil grasp, inconsistent letter formation, and slow writing speed. He struggled with fastening buttons and tying shoelaces. Cutting skills were laboured and inaccurate, indicating challenges with bilateral coordination and hand-eye coordination. Gross motor skill observations highlighted difficulties with navigating obstacles, maintaining balance on uneven surfaces, and coordinating movements during hopping and skipping. His overall body awareness appeared somewhat diminished, as he often bumped into objects. Sensory processing observations indicated a tendency to seek deep pressure, often leaning against surfaces or requesting tight hugs. He appeared to be easily distracted by auditory stimuli in the clinic environment. He demonstrated some challenges with modulating his responses to sensory input. Bilateral coordination and crossing midline observations revealed difficulties with activities requiring both hands to work together, such as opening a jar or catching a ball. He often avoided crossing the midline during drawing tasks, favouring one side of the paper. Handwriting observations showed immature letter forms, inconsistent spacing, and overall poor legibility. Social observations indicated that Leo engaged appropriately with the therapist, making eye contact and responding to questions, but also expressed some frustration regarding his physical abilities in comparison to peers. Summary: Overall assessment findings indicate that Leo presents with Developmental Coordination Disorder (DCD), as evidenced by his scores on the Movement ABC-3 and clinical observations of motor skill deficits that significantly impact his daily functioning. His difficulties are further compounded by aspects of his ADHD, which may influence his attention and sustained effort on motor tasks. Leo's strengths in verbal communication and imaginative play can be leveraged in therapy. Recommended interventions will focus on a multi-modal approach, including direct intervention for fine and gross motor skills, sensory regulation strategies, and collaborative goal setting with parents and school. Specific recommendations include a weekly occupational therapy session focusing on handwriting, bilateral coordination, and balance activities. Parents will be provided with strategies to incorporate motor skill practice into daily routines. Prognosis is good with consistent intervention and support. Goals for therapy include improving handwriting legibility and speed, enhancing fine motor dexterity for self-care tasks, and developing greater confidence and participation in gross motor activities.