ILLINOIS EARLY INTERVENTION
OCCUPATIONAL THERAPY EVALUATION/ASSESSMENT REPORT
SECTION 1: Demographic Information
Child’s Name:
EI #:
Date of Birth: 11/4/15
CFC #:
Chronological Age: 22 months
Adjusted Age: 20 months
Date of Evaluation/Assessment or Assessment: 9/28/2017
Parent’s Name:
Language Spoken in home: Chinese and English
Service Coordinator’s Name:
Physician’s Name:
SECTION 2: Type of Report
Check One:
Evaluation/Assessment (for Eligibility Determination)
Provider Name:
Provider Discipline:
X
OT
PT
X
Assessment (if child already eligible)
Provider Phone Number:
SLP
SW
Other:
DT
Location of Evaluation/Assessment: (check one) X
Home
Other Setting (identify where):
SECTION 3: Referral Information
Please list reason for referral, who referred to Child & Family Connections, and Parent/Guardian Concerns:
was initially evaluated in April 2017 for the EI program due to concerns with speech and motor skills. He was
evaluated by developmental, speech, and physical therapy and qualified for all three services at one time per week. He
was recommended to be evaluated by occupational therapy by his ongoing therapists as he closed in on his 6 months
in the EI program.
At this time, his parents feel that he has made some good progress, but they continue to have concerns with his speech
and now some of his fine motor skills.
SECTION 4: Instrument(s) Administered during Evaluation and/or Assessment
Title of Instrument Used
Developmental Domain Addressed
Age Equivalent*
Percent of delay*
PDMS-2 : Peabody
Motor (Fine Motor)
Developmental Motor
Scales, 2nd Edition
14 months
33% Delay
Grasping Subtest - Standard Score 8
Visual Motor Coordination Subtest - Standard
16 months
24% Delay
Score 5
*Required for Evaluation/Assessment. If completing Assessment only, provide if known.
Sensory Processing Skills are informally assessed during the assessment through the use of questions based off of the
Infant/Toddler Sensory Profile and clinical observations of the child in functional play and participation. Results are
quantified as
 Typical – processing sensory information in the environment as typical peers or
 Atypical- difficulties processing and learning from sensory information in the environment
Your child’s Sensory processing abilities as observed during the assessment - ATYPICAL Variable
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NAME:
EI #:
SECTION 5: Evaluation and/or Assessment
A. Child’s developmental history and summary of parents’ concerns:
is from a loving, caring family.
He lives with his biological parents and his grandfather is currently living with him.
spends his days with
his mother or grandfather and at times a caretaker. The Chinese language is the primary language spoken in
the home.
parents expressed concerns with their son’s speech skills.
was reported to have sat at 1 year, crawled at 1 year, and began walking at 18 months. He attends a
church program once a week and has a hard time transitioning away from his parents initially. He will then
calm and explore the room. Parents report that he is not yet playing with other kids.
B. Summary of medical history:
Medical/Birth History and Reports: Medical history as reported by parent.
Pregnancy/Delivery: Mother reported nausea and was on Zofran during the pregnancy. From the 10th week to
5th month of pregnancy mom had gestational diabetes managed with diet. Mom’s water broke at 35 weeks 5
days. Labor was induced. He was born via vaginal deliver weighing 5lbs 11oz. He had jaundice at birth treated
with light therapy. He passed newborn hearing screenings. No complications occurred during or following
delivery and he was discharged home with his parents. No emergency room or hospital visits.
General Health: Good general health to date.
C. Behavioral Observations of the child:
greeted the therapist at the door with his mother. He initially
made fleeting eye contact and was more interested in the items contained in the bag the therapist brought. He
was able to be redirected to one of his own toys briefly and then began to engage with the therapist’s
activities. He made more purposeful eye contact in the context of play, but continued to have decreased eye
contact. He was able to participate in the various tasks, but struggled to transition between some of the
activities. Mom reported that these were more preferred tasks for him. She reports that his ability to transition
between tasks has greatly improved since beginning therapy sessions. Results are felt to be an accurate
representation of
skills at this time.
D. Child’s level of functioning (identifying strengths and needs) in each of the developmental areas tested:
Motor Domain – Fine Motor Skills assessed:
The PDMS-2 looks at two main areas of assessment for fine motor development in children. The grasping
subtest refers to how a child picks objects up and the visual motor subtest refers to how a child’s vision and
motor coordination systems are working together to accomplish various tasks.
grasping skills are
assessed to be at the 14-months age equivalency and his visual motor skills are assessed to be at the 17month old level. The grasping skills are felt to be lower because
needs more information from objects
and using less mature grasping patterns so that he can feel the object in its entirety in his hands.
Grasping:
Strengths –
engaged with the presented toys. He demonstrated a fisted grasp on 1” blocks with no
open web-space visible. This is a less mature grasping pattern than we would like to see at this age. He used a
lateral pinch grasp to pick up small food pellets, instead of the more refined pincer grasp. He was not able to
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NAME:
EI #:
hold two cubes in one hand. He banged the blocks together and was able to do so when given a verbal
command. When presented with a marker, he was able to scribble and engage in the task.
Concerns –
appears to be using his whole hand to manipulate objects. He is not yet demonstrating
more of the refined grasping patterns that we would like to see at this age. Using resistive materials, tactile
materials and providing him with sensory input prior to completing fine motor tasks can help
to begin
to use more mature grasping patterns. Continue to work on exposing him to crayons, chalk, markers, and
paint brushes to have him gain familiarity with these tools.
Visual Motor
Strengths –He could place blocks in a cup and dump the cup of the contents. He was able to hand them to the
evaluator. He was able to place 4 blocks in a cup before becoming distracted with the task. He built a 3-block
tower and attempted to build higher, but he demonstrated too much force to be able to stack the next block
on top.
was not able to remove the lid from a small container, but he was able to dump the contents.
was able to turn pages of the book and isolate his index finger to point. He did imitate basic actions
during the assessment (tapping with a spoon on a cup), but did not demonstrate some of the higher-level
tasks.
Concerns –
was able to sit and complete several tasks at a time, prior to needing a movement break.
Once he had a quick break, he was able to come back and continue working on the task. Once
performed a task one way (stacking a block tower) he was not able to shift to be able to attempt to make a
block train and wanted to repeat the tower-stacking activity.
Sensory This is the ability to take in sensory stimuli, process it, and produce an adaptive response. Sensory
stimulus is anything in the environment that is perceived by our senses through our vision, hearing, tasting,
smelling, tactile, and movement. Stimuli are perceived through our senses and sent to our central nervous
systems to produce a response. How sensory stimulus is perceived can greatly affect a child’s attention span
and overall body organization. Children that have difficulty processing this information convey this through
atypical reactions. These include decreased attention, low frustration tolerance, and over responsiveness or
under responsiveness to normal environmental conditions. Sensory processing difficulties often affect a
child’s ability to learn properly from his/her environment.
 Vision: Visual activities include processing information from our environment including light, color, and
shapes. Visual processing includes the ability to attend to necessary information and ignore
information that is not relevant.
is reported to at times watch or become fixated on spinning
objects such as fans or wheels. He will look at himself in a mirror.
 Auditory Processing: Auditory activities involve the ability to process various sounds and intensities of
sound along with the ability to filter out or ignore sounds that are not relevant. Mom reports that
does not always respond to his name when called, depending on what he is engaged in. He
does not appear to be bothered by loud sounds.
 Tasting/Feeding and Smelling:
is described as a picky eater. He will avoid various textures of
foods and gag/spit the items he does not want.
 Movement (Vestibular and Proprioception) and Coordination: The vestibular system refers to
structure within the inner ear that detects movement and changes in the position of the ear. It aids in
eye coordination, head, and body movements. It also plays a part in motor planning, bilateral
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NAME:
EI #:
coordination, muscle tone, movement, and balance.
enjoys movement and is reported to
always be climbing. He does not demonstrate any awareness for his safety when climbing. He has not
had a lot of exposure to activities outside the home. Encouraging the use of a local playground,
playing in the grass space near his home, or going to play places would benefit his exposure to more
varied activities.
 Touch (tactile) processing: Tactile sensation refers to our ability to interpret stimuli received by the
skin. This stimulation may be in the form of touch, pain, pressure, or temperature. The tactile system
includes two components; a protective component, which tells us that we are in contact with
something pleasant or dangerous, and a discriminatory component, which allows us to determine
where we are being touched and what it is that is touching us.
isn’t bothered by clothing
fabrics or tags. He will cuddle with his family on his terms. He does not like tactile play, but this is
getting a little better dad reports due to the things he is working on in therapy. He is beginning to
tolerate grass. He has not had exposure to sand or playdoh.
Attention/Behavior/Play
demonstrated interest in play tasks initially, but had some difficulty sustaining attention throughout.
He had some difficulty attending to novel tasks or tasks that required him to use an object in a way that he
did not want to use it. During transitions, he would attempt to leave the task or wanted to play repetitively
with a toy.
has been demonstrating some tantrum behaviors. Typically, when being told ‘no’ or having
to leave something that he enjoys. He has been calming quickly when upset. He reportedly likes the cellphone
and tablet and prefers these types of activities. He has been getting these items less frequently and has been
turning them over with less distress his dad reports.
Strength/Range of Motion/Muscle Tone:
demonstrates decreased strength and postural control for
functional activities. He demonstrates frequent squatting to access toys on the floor. He demonstrates a
wide-based w-sit as well.
Self-Help Skills
Feeding:
is interested and attempts to use a spoon to feed himself, but doesn’t always use it. He will
accept hand over hand assistance with the spoon. He will take an 8-oz bottle 3 times per day of formula.
Strategies to help the family reduce the bottle and increase his eating of table foods should be worked on
during therapy sessions.
Bathing/Dressing/Toileting:
enjoys bath time. He cooperates with dressing, but is not doing any skills
independently.
Sleeping:
takes approximately one hour to fall asleep at night. He is napping later in the day. He would
benefit from moving his nap slightly earlier in the day to help support his sleep in the evening.
E. Provide justification for annual re-determination for children not meeting original eligibility criteria:
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NAME:
EI #:
SECTION 6: Summary and Interpretation
A. Brief summation of the child’s unique strengths and needs, ability to perform functional skills and how
the child is able to participate in family routines:
is and adorable 22-month (adjusted age 21 month) old little boy. He is demonstrating an increased
interest in toys and is participating in many routine activities throughout his day, since beginning therapy
services with DT, PT, and ST. He enjoys books, cars and blocks, but at his time, he is demonstrating some
repetitive play with the materials. He can be frustrated if his play is interrupted and changed. Dad reports that
he will frequently seek movement in his environment and does not appear to have a concept of danger or his
safety yet. He has preference for certain toys and for playing certain ways and did not always want to
demonstrate the flexibility to change or accept new play patterns. He does demonstrate a need for increased
movement and proprioceptive input in his play.
would benefit from increasing his engagement in tasks
and his joint attention with people and objects. He would benefit from working on his ability to imitate motor
actions of others.
is processing some sensory information in his environment somewhat different than
his peers. He is sensitive to textures on his hands of tactile materials and in his mouth of food materials. He is
not yet eating a variety of foods to help support a healthy diet. He would benefit from continued exposure to
tactile play, movement-based play activities, and opportunities to engage with other children his age and
learn from his play with them at times as well.
B. If applicable, recommendations for referrals for additional EI assessments and/or other resources
outside of Early Intervention to be discussed at the IFSP meeting:
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