Pleаse reаd the fоllоwing оccupаtional therapy evaluation report completed by the OTR. LTGs and STGs have been established. Develop an appropriate treatment plan-interventions-for each Short-Term Goal. Please assign your interventions to the appropriate category as defined in Occupational Therapy Practice FRAMEWORK: Domain and Process, 4th Edition. Please provide an appropriate justification or rationalization for your interventions. Student: AmyGrade: Second GradePrimary Setting: Elementary School Background and Reason for Referral Amy is a second-grade student who recently transferred to her current school from another state. Her classroom teacher has expressed significant concerns regarding Amy’s overall development, particularly her fine motor and gross motor skills. These difficulties appear to affect her ability to participate successfully and independently in several school occupations. Amy’s parents are supportive and have also expressed concerns regarding her school performance. Prior to moving, Amy received an occupational therapy screening at her previous school. Her parents questioned whether the screening adequately represented Amy’s abilities because it was completed quickly near the end of the school year. Occupational Performance and School Participation Amy demonstrates difficulties in several areas of occupational performance that are important to her role as an elementary school student. Her motor challenges affect her participation in classroom activities, self-care routines, physical education, recess, and potentially social participation with peers. Within the classroom, Amy demonstrates fine motor difficulties that may interfere with completing age-appropriate academic tasks. She has been observed using a supinated grasp during writing activities and has difficulty holding and manipulating scissors. These challenges may affect the efficiency, accuracy, and independence with which she completes written assignments, art projects, cutting activities, and other classroom tasks requiring manipulation of school materials. Activities of Daily Living and School Routines Amy demonstrates decreased independence with dressing activities required during the school day. She currently requires moderate assistance to put on her jacket and tennis shoes for recess. Difficulty completing these tasks independently may affect Amy’s ability to transition efficiently between classroom activities and recess or other school activities. Dressing tasks require multiple performance skills, including bilateral coordination, fine motor manipulation, motor planning, sequencing, balance, and body awareness. Further assessment would be appropriate to determine which specific factors are contributing to Amy’s difficulty. Gross Motor and Physical Participation Amy demonstrates concerns related to overall body coordination and has difficulty participating fully in physical education and recess. Previous BOT testing identified delays in body coordination. These difficulties may limit Amy’s participation in age-appropriate gross motor activities such as running, jumping, climbing, navigating playground equipment, participating in games, and engaging in activities requiring balance and bilateral coordination. Additional assessment and observation would be needed to determine the specific gross motor activities that are most challenging for Amy. Social Participation Amy has frequently been observed sitting alone during recess. This is an important occupational performance concern because recess provides opportunities not only for gross motor activity but also for social interaction, cooperative play, friendship development, and participation with peers. The available case information does not establish why Amy sits alone. Her reduced participation could potentially be related to her motor challenges, her recent transition to a new school, difficulty accessing playground activities, or other factors that have not yet been identified. The occupational therapy evaluation should explore Amy’s perspective on recess, preferred activities, peer relationships, and any environmental or performance barriers affecting her participation. Assessment Information At her previous school, Amy was administered the short form of the Bruininks-Oseretsky Test of Motor Proficiency (BOT). Results indicated delays in fine motor integration and overall body coordination. Clinical observations also identified a supinated grasp during writing, difficulty holding and manipulating scissors, decreased independence with dressing for recess, need for moderate assistance with her jacket and tennis shoes, and decreased participation in physical education and recess. These findings support the need for a more comprehensive occupational therapy evaluation to determine how Amy’s motor performance is affecting her participation in educationally relevant occupations. Strengths and Supports An important strength is Amy’s supportive family. Her parents have advocated for further evaluation and have expressed concern regarding her school performance. Amy also has a teacher who has recognized her difficulties and is identifying areas in which additional support may be needed. Amy’s recent transition to a new school provides an opportunity for the educational team to establish supports and interventions that promote successful participation in her new environment. Areas Requiring Further Assessment Because an occupational profile should reflect the student’s and family’s priorities, additional information should be gathered directly from Amy, her parents, teacher, and other relevant school personnel. Areas to explore include Amy’s interests and preferred activities; feelings about school and her recent move; preferred classroom and recess activities; peer relationships and social participation; perception of activities that are easy or difficult; handwriting and classroom fine motor performance; bilateral coordination and manipulation skills; gross motor coordination and balance; dressing and other school-related self-care skills; ability to transition between school routines; and environmental factors that support or interfere with participation. Occupational Therapy Priorities Based on the available occupational profile, OT services should focus on determining how Amy’s fine motor, bilateral coordination, body coordination, and motor planning abilities affect her participation in meaningful school occupations. Intervention should emphasize functional participation rather than isolated motor skills. Priority occupations include classroom writing and cutting tasks, dressing for recess, participation in physical education and playground activities, and increased independence in school routines. Collaboration with Amy, her parents, teacher, and other educational team members will be important in developing interventions that support Amy’s successful participation across school environments. Established Occupational Therapy Goals Long-Term Goal – 1 Academic Year Within 1 academic year, Amy will demonstrate improved fine motor coordination, bilateral coordination, and motor planning to independently participate in school-related fine motor and self-care activities (e.g., writing, cutting, donning jacket, and donning shoes) with no more than minimal assistance in 4 out of 5 opportunities, as measured by therapist and/or teacher observation. Short-Term Objective 1 – 1 Semester Within 1 semester, Amy will demonstrate improved fine motor and bilateral coordination by using a functional grasp during writing and independently positioning and manipulating scissors to cut along a ¼-inch-wide curved or straight line with at least 80% accuracy in 4 out of 5 opportunities. Occupations and Activities: (2 Points) Interventions to Support Occupations: (2 Points) Education and Training: (2 Points) *Justification or Rationalization for your interventions: (2 Points) Short-Term Objective 2 – 1 Semester Within 1 semester, Amy will demonstrate improved bilateral coordination and motor planning by donning her jacket and tennis shoes for recess with no more than minimal assistance and no more than 2 verbal cues in 4 out of 5 opportunities. Occupations and Activities: (2 Points) Interventions to Support Occupations: (2 Points) Education and Training: (2 Points) *Justification or Rationalization for your interventions: (2 Points)
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