| 5389 | | Plan Date: 03-25-2026 | | Occupational Assessment Summary: Alejandra is a 14-year, 3-month-old female with a complex medical history including DiGeorge Syndrome, Cerebral Palsy, Autism, and a history of grand mal seizures, who was evaluated to determine her current level of function and need for skilled occupational therapy services. Based on parent report, formal assessment, and skilled clinical observation, Alejandra presents with significant and pervasive deficits across multiple functional domains. Her functional performance is significantly impacted by distractibility, severely delayed response rates, and resistance to cooperation, which compromised the reliability of standardized testing but provided critical qualitative insight into her functional challenges. A recent history of functional regression, specifically the loss of ability to walk with one-hand-held support following a seizure five months ago, underscores the fragility of her current skill set and the need for therapeutic intervention to prevent further decline. Objective assessment using The Roll Evaluation of Activities of Life (REAL) revealed a standard score of 75.6 on the Activities of Daily Living (ADL) domain, which falls below the 1st percentile for her age. This score is more than -1.5 standard deviations below the normative mean, quantitatively confirming a significant deficit in her ability to perform essential self-care tasks independently. These ADL deficits are directly compounded by profound delays in underlying fine-motor and visual-motor skills. At 14 years and 3 months of age, Alejandra demonstrates foundational grasp patterns, such as a raking grasp for small objects, and has not yet developed a pincer grasp, reflecting a fine-motor delay of many years, thereby far exceeding the six-month delay criterion. She exhibits notable muscle weakness in her bilateral upper extremities, with greater weakness in the right upper extremity, which impairs her ability to engage in bilateral tasks and limits functional reach and grasp. The combination of these motor deficits severely restricts her independence in dressing, feeding, and personal hygiene. Furthermore, significant deficits in sensory processing and regulation serve as a primary barrier to functional participation. Clinical observations revealed hyper-responsiveness to auditory and vestibular input alongside significant gravitational insecurity, contributing to a frequent state of over-arousal, anxiety, and avoidance of age-appropriate movement activities. Her difficulty with self-regulation directly impacts her attention, ability to cooperate with directives, and social engagement, where she presents as withdrawn. These sensory, emotional, and behavioral challenges are functionally equivalent to those of a much younger child and profoundly impact her ability to participate safely and effectively in her home, school, and community environments. The convergence of these deficits creates a clinical picture of an adolescent requiring extensive support for all daily occupations. In summary, the combination of quantifiable delays in self-care, severe fine-motor and visual-motor deficits, and pervasive challenges with sensory processing, self-regulation, and attention result in profound functional impairment. These deficits prevent meaningful participation in her development of peer relationships, increase caregiver burden for all ADLs, and pose significant safety concerns. Therefore, skilled Occupational Therapy services are determined to be medically necessary to address these measurable deficits, reduce the risk of further functional regression, and improve her independence and safety. Due to the severity and multiplicity of deficits across all domains, her recent functional decline, and significant safety risks, a treatment frequency of two sessions per week is recommended. This intensity is required to simultaneously address foundational sensory-regulatory needs, remediate fine-motor and bilateral coordination deficits impacting ADLs, and implement strategies to improve safety and cooperation. A lower frequency or postponement of treatment would place Alejandra at high risk for a widening of the already significant gap between her functional abilities and age expectations, further compromising her long-term potential for independence.
| | Occupational Rehabilitation Potential: Good. with consistent Occupational Therapy and parental support | | Occupational Treatment Plan: Alejandra is a 14-year, 3-month-old female with a complex medical history including DiGeorge Syndrome, Cerebral Palsy, Autism, and a history of grand mal seizures, who was evaluated to determine her current level of function and need for skilled occupational therapy services. Based on parent report, formal assessment, and skilled clinical observation, Alejandra presents with significant and pervasive deficits across multiple functional domains. Her functional performance is significantly impacted by distractibility, severely delayed response rates, and resistance to cooperation, which compromised the reliability of standardized testing but provided critical qualitative insight into her functional challenges. A recent history of functional regression, specifically the loss of ability to walk with one-hand-held support following a seizure five months ago, underscores the fragility of her current skill set and the need for therapeutic intervention to prevent further decline. Objective assessment using The Roll Evaluation of Activities of Life (REAL) revealed a standard score of 75.6 on the Activities of Daily Living (ADL) domain, which falls below the 1st percentile for her age. This score is more than -1.5 standard deviations below the normative mean, quantitatively confirming a significant deficit in her ability to perform essential self-care tasks independently. These ADL deficits are directly compounded by profound delays in underlying fine-motor and visual-motor skills. At 14 years and 3 months of age, Alejandra demonstrates foundational grasp patterns, such as a raking grasp for small objects, and has not yet developed a pincer grasp, reflecting a fine-motor delay of many years, thereby far exceeding the six-month delay criterion. She exhibits notable muscle weakness in her bilateral upper extremities, with greater weakness in the right upper extremity, which impairs her ability to engage in bilateral tasks and limits functional reach and grasp. The combination of these motor deficits severely restricts her independence in dressing, feeding, and personal hygiene. Furthermore, significant deficits in sensory processing and regulation serve as a primary barrier to functional participation. Clinical observations revealed hyper-responsiveness to auditory and vestibular input alongside significant gravitational insecurity, contributing to a frequent state of over-arousal, anxiety, and avoidance of age-appropriate movement activities. Her difficulty with self-regulation directly impacts her attention, ability to cooperate with directives, and social engagement, where she presents as withdrawn. These sensory, emotional, and behavioral challenges are functionally equivalent to those of a much younger child and profoundly impact her ability to participate safely and effectively in her home, school, and community environments. The convergence of these deficits creates a clinical picture of an adolescent requiring extensive support for all daily occupations. In summary, the combination of quantifiable delays in self-care, severe fine-motor and visual-motor deficits, and pervasive challenges with sensory processing, self-regulation, and attention result in profound functional impairment. These deficits prevent meaningful participation in her development of peer relationships, increase caregiver burden for all ADLs, and pose significant safety concerns. Therefore, skilled Occupational Therapy services are determined to be medically necessary to address these measurable deficits, reduce the risk of further functional regression, and improve her independence and safety. Due to the severity and multiplicity of deficits across all domains, her recent functional decline, and significant safety risks, a treatment frequency of two sessions per week is recommended. This intensity is required to simultaneously address foundational sensory-regulatory needs, remediate fine-motor and bilateral coordination deficits impacting ADLs, and implement strategies to improve safety and cooperation. A lower frequency or postponement of treatment would place Alejandra at high risk for a widening of the already significant gap between her functional abilities and age expectations, further compromising her long-term potential for independence. | | Occupational Long Term Goals: | | Category | Goal Description | | Home Management Intervention Program | Within 6 months, the child and caregiver will demonstrate consistent participation in the prescribed home exercise program by completing activities, with the caregiver reporting improved carryover of targeted skills during daily routines. | | Sensory Issues/Self Regulation | Within 6 months, Alejandra will demonstrate improved self-regulation and social interaction skills by redirecting grabbing, pinching, pulling behaviors into appropriate alternatives in 4 out of 5 opportunities with minimal support across 4 consecutive sessions. Currently Alejandra will grab, pinch, and pull others hair when she gets excited or upset which greatly limits her opportunity to engage with others and for learning opportunities. | | Sensory Issues/Self Regulation | Within 6 months, through use of sensorimotor play, Alejandra will engage in play with another person with a familiar toy or activity for at least 1 minute, demonstrating shared attention and participation, in 4 out of 5 opportunities, with minimal support to improve self-help skills. Currently Alejandra is engaging in play with another for a few seconds provided maximum support which impacts her ability to learn and participate in self-care activities. | | Self Care | Within 6 months, Alejandra will increase independence with dressing by lifting arms and threading them through sleeves when donning a shirt, completing the task in 4 out of 5 opportunities with minimal support. Currently mother is placing her hands in the sleeves and providing support for her to push them through. | | Fine Motor | Within 6 months, Alejandra will improve bilateral coordination by using both hands together to pull apart and/or join objects (e.g., connecting toys) in 4 out of 5 opportunities with minimal assistance. |
| | Occupational Short Term Goals: | | Category | Goal Description | | Sensory Issues/Self Regulation | Within 3 months, Alejandra will demonstrate improved self-regulation and social interaction skills by redirecting grabbing, pinching, pulling behaviors into appropriate alternatives in 3 out of 5 opportunities with moderate support across 4 consecutive sessions. Currently Alejandra will grab, pinch, and pull others hair when she gets excited or upset which greatly limits her opportunity to engage with others and for learning opportunities. | | Sensory Issues/Self Regulation | Within 3 months, through use of sensorimotor play, Alejandra will engage in play with another person with a familiar toy or activity for at least 30 seconds, demonstrating shared attention and participation, in 3 out of 5 opportunities, with moderate support to improve self-help skills. Currently Alejandra is engaging in play with another for a few seconds provided maximum support which impacts her ability to learn and participate in self-care activities. | | Self Care | Within 3 months, Alejandra will increase independence with dressing by lifting arms and threading them through sleeves when donning a shirt, completing the task in 3 out of 5 opportunities with moderate support. Currently mother is placing her hands in the sleeves and providing support for her to push them through. | | Fine Motor | Within 3 months, Alejandra will improve bilateral coordination by using both hands together to pull apart and/or join objects (e.g., connecting toys) in 3 out of 5 opportunities with moderate assistance. |
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