Occupational Therapy Evaluation

Ella is 8 yrs and 9 months old. She was found to have a lack of proper myelination when she was about 6 years old, due to yearly MRIs and EEGs from her seizure disorder followup. The myelination experts told me that her delays and sensory issues were due to the lack of myelination, but never explained it to me, and did not do any further followup.. just prescribed OT, PT, and Sensory Therapy. She had OT and PT (but not really any ST) when she was 6-7 yrs old, and I was not very happy about the place she was getting services. We switched to another office, and I love her therapist, and how comprehensive this evaluation was!

I will be meeting with her OT next week to go over the eval in more depth, but I wanted to post the findings here. I have been aware of Ella's gross and fine motor delays and sensory issues for almost 3 years, but she was officially diagnosed with Sensory Processing Disorder including Sensory Modulation Dysfunction, Auditory Processing Disorder, and Developmental Dyspraxia. The eval reported that on most of her issues, she is 2 standard deviations below the norm.

I am looking forward to working with the therapist to FINALLY get Ella going with a sensory diet. And I am interested to figure out how her low tone and postural issues, Auditory Processing Disorder, and Visual Motor delays are affecting our schooling, and what I can do/buy/provide. Let me know what you have used or are aware of if any of this looks familiar!

I have the full report if you're interested, but here are my notes.

Sensory Processing Disorder

Definition of sensory integration:
Sensory integration is the neurological process in which the brain organizes and interprets sensory information for use in daily life. Effective sensory processing allows a person to efficiently respond to environmental stimuli. Sensory input is received through several systems.. tactile, auditory, visual, taste, smell, proprioceptive (muscle and joint receptors in the body which provide information regarding the body's position in space), and vestibular (input to the receptors of the inner ear which respond to motion and changes in head position that contribute to the development of balance reactions, muscle tone, ocular control, bilateral integration, and the body's relationship to gravity). Sensory input provides a child with information about her environment. Appropriate sensory processing is necessary for a child to interpret environmental information and use it to successfully and purposefully respond to the demands within that environment.  All sensory information has to be organized and processed in order for an individual to respond adaptively. Some children may have difficulty processing, or making sense, of sensory input, and as a result of "faulty processing" demonstrate a variety of behaviors in accordance with their neurological thresholds.

Behavioral observation:
during fine motor evaluation, she was cooperative and talkative, demonstrated appropriate social skills and appropriate eye contact with therapist. After demonstrating some difficulty with suspended equipment, she quickly gravitated toward more sedentary activities such as drawing and writing.

 She needed prompting from therapist to more fully explore her surroundings.
 Ella was noted to become more animated and talkative after participating in several gross motor activities. She was observed to have trouble with motor planning to access several pieces of equipment and needed coaching from the therapist to keep trying when the activity proved to be challenging.
Ella used several compensatory strategies when faced with challenging gross motor activities.
She was noted to try and redirect play to more controlled activities such as pretend play, she would try to talk her way out of activities, and she also exhibited flight behaviors and refused to participate in activities completely.
Ella was able to develop, explain, and implement problem solving strategies to help modify activities so they were less challenging in some instances.
Ella was observed to seek out vestibular input through spinning, she appeared to need more intensity than other peers to reach her threshold, as evidenced by holding her head back to intensify rotary input yet never reaching a dizzy state during the activity.
Ella had difficulty motor planning through multi step directions given by therapist and demonstrated some trouble sequencing actions that required timing or complex movement patterns, she did better with these tasks when they were visually demonstrated by the therapist or a peer.
 Ella displayed poor balance and low postural tone as evidenced by difficulty walking over large floor pillows and difficulty shifting weight to access suspended equipment.

Part 2:

Sensory Defensiveness:
in individuals with sensory defensiveness, the protective system overrides the discriminatory system, often resulting in hypersensitive responses to sensory input. It is an unusual degree of anxiety or discomfort as response to sensory events in the environment which are typically not threatening. These responses typically take the form of fight (reactive, explosive), flight (escape, distractible), or fright (reluctance, whiny, tearful). It can effect activity level (arousal), behaviour, and emotions as well as motor responses.

Ella exhibits sensory defensiveness in reaction to certain auditory, tactile, visual, and some types of vestibular sensory input that her body perceives as harmful.

Tactile:
  Ella exhibits significant hyper-responsivity, or avoidant behaviors to tactile input. Once she reaches her high threshold for tactile registration, she responds quickly with intense behaviors that may be considered extreme for the type of stimulus. For example, she may have a tantrum or a meltdown when asked to do grooming activities like brush her hair, or wear itchy, uncomfortable clothing. These behaviors are characteristic of a Sensory Modulation Disorder.

Oral Sensory:
Averse to meat and rice, and other food textures. Food texture avoidance is a characteristic of a Sensory Processing Disorder.


Auditory:
  Ella exhibits hypersensitivity to auditory input. She is fearful of loud and high pitched noises often causing her to run away from these experiences or cover her ears. She is easily distracted in noisy environments, she has trouble working when there is background noise present, and she often has difficulty paying attention to auditory commands when in busy settings. Ella displays characteristics of an Auditory Processing Disorder as indicated by hyper-responsive behaviors to auditory input.

Visual:
Ella demonstrates some hypersensitive behaviors in response to visual input. She also has some trouble with letter reversals when writing. These characteristics can indicate difficulty processing visual input.

Proprioceptive:
Sense of muscle and joint activation, which provides information to the brain regarding the body's position in space and the grading of one's movement. Receptors in the muscles and joints are stimulated through activities such as pulling, pushing, climbing, jumping, and other resistive type of activities. Proprioceptive input is organizing to the nervous system as it brings the individual to a calm alert state.

  Ella displays hypo responsive behaviors in regard to proprioceptive processing. She was able to complete more challenging and complex tasks after engaging in activities that provided strong proprioceptive feedback. She was more calm, organized, and alert.

Vestibular
Important for behaviour and motor coordination de to its contributions of balance and equilibrium reactions, muscle tone, coordination of eye and hand movements, ability to use both sides of the body together, arousal, and some aspects of language development.

Ella displayed both over and under responsiveness to vestibular input. She displays poor endurance and tires easily. She tends to seek out movement activities especially when she is trying to concentrate during homework or school related tasks. She has difficulty interpreting some types of vestibular input such as a fear response with heights. Ella also sought out spinning activities during the clinical observations, she displayed under responsiveness to rotary (going in a circle) input and seemed to need more of this type of input than other children to elicit a dizziness response. Ella's challenges with crossing the midline, letter reversals, delayed visual motor skills, and poor motor planning are also consistent with vestibular processing challenges.

Arousal:
An individuals state of alertness. Some people have high arousal level and are constantly on the go, and have a hard time calming down. Others present with a low arousal level in which they appear more lethargic, disinterested, and disengaged from their environments. Ella has difficulty modulating her arousal to a "just right" place. She tends to stay in a constant state of high arousal where she is constantly on the verge of shifting into sensory overload. Her sensory sensitivities to certain inputs can cause her arousal to escalate quickly and result in over stimulation. which can result in protective responses such as anxiety attacks, shut down, limited frustration tolerance, and flight from activities. It was noted was noted that Ella demonstrated more appropriate organization and attention to task through the gross motor portion of the evaluation, and this modulation was partly contributed to the intense amount of proprioceptive input these activities provided her.

Motor performance:
  Ella's range of motion and strength appeared to be within normal limits, however, she did exhibit characteristics of low muscle tone. She also had difficulty maintaining an upright posture when walking over oversized pillows on the floor, indicating that her postural responses are diminished due to her under-responsive vestibular system. When allowed to seek out input in a sensory enriched environment, Ella sought out intense vestibular input such as swinging across a zip line or spinning in the hammock. These activities have an alerting and organizing effect on Ella. She had difficulty with gross motor planning and execution. She has difficulty figuring out how to coordinate her body to complete complex motor tasks, like copying movement patterns demonstrated by the therapist. She also shows difficulty coordinating movements that cross the midline of her body, indicating difficulty with bilateral separation. Overall, Ella’s gross motor skills are below average for a child of her age. She is quick to fatigue, and has a low frustration tolerance for challenging activities. She also has difficulties with sequencing and motor planning.  Ella's difficulties with planning and organizing complex motor movements are consistent with the diagnosis of dyspraxia. Based on observation and parent report, her primary areas of need are within the organization and initiation stages of praxis.

Visual Motor Skills
Ella's visual motor integration and motor coordination skills are lower than average for a student her age. Her visual perception scores are higher than average for a student her age. When faced with a motor coordination component to a visual perception task, her abilities are taxed. From a developmental dyspraxia standpoint, Ella must cognitively put forth more effort to accomplish these types of tasks due to the motor challenges involved. Although her brain is correctly and efficiently processing visual input, delays with motor skills impair her visual motor integration skill. Ella was able to copy basic shapes, but presented with more complex pictures, she had difficulty with sizing, spacing, and directionality of lines to copy more complex forms.

Recommendations:
1. Occupational Therapy using a sensory integrative approach and fine motor development are recommended to address the issues that are negatively impacting Ella's ability to function at home, school, and in the community. 1 hr a week

2. It is recommended that a Therapeutic Listening home program be implemented with Ella. The primary goals are to decrease auditory sensitivity to loud and unexpected noise, and to improve auditory processing to help Ella filter out extraneous background noise.

3. It is recommended that Ella participate in a sensory diet at home and at school. A sensory diet is a plan of sensory based strategies used throughout the day to assist with appropriate sensory processing and modulation of arousal. Ella's sensory diet should specifically include proprioceptive and vestibular input since these are currently means by which she is seeking organization.

4. Ella may benefit from a therapeutic skin brushing protocol to facilitate body awareness, modulate arousal, and decrease tactile sensitivities.

5. Ella should continue to participate in therapeutic strategies to help her improve her writing skills, handwriting without tears handwriting program, ocular motor skill development, improvement of distal motor coordination, and strengthening of trunk and upper extremities for improved postural and distal control.

I am also going to talk to her OT about putting together an Individualized Educational Program (IEP) for homeschooling.