| 5369 | | Plan Date: 03-04-2026 | | Occupational Assessment Summary: Zaria is a 4-year, 2-month-old female who presents for an occupational therapy evaluation to determine her current level of function. Clinical findings from standardized assessment, informal observation, and caregiver report reveal significant delays across sensory processing, social-emotional development, and performance of activities of daily living, which adversely impact her functional participation in home and community environments. Throughout the evaluation, Zaria presented as highly distractible with poor cooperation, requiring numerous prompts to engage in structured tasks, which calls into question the reliability of standardized scores and suggests her functional deficits may be even greater than measured.
The patient demonstrates significant deficits in sensory processing and emotional regulation, with functional skills estimated to be delayed by more than twelve months, a level of performance consistent with scores falling more than -1.5 standard deviations below the mean. These challenges manifest as persistent sensory-seeking behaviors, such as crashing and jumping, and poor self-regulation, resulting in frequent emotional outbursts that are disproportionate to the situation. Her social and play skills are also substantially delayed, functioning at a level commensurate with a 24 to 30-month-old child, which reflects a quantifiable delay of 20-26 months and is consistent with performance greater than -2.0 standard deviations below the mean. Functionally, these core deficits in regulation and social interaction impede her ability to maintain attention for learning, follow directions in a preschool setting, and engage in cooperative, reciprocal play with peers, leading to social withdrawal.
These foundational deficits directly and negatively impact the patient’s independence in self-care. On the Roll Evaluation of Activities of Life (REAL), a formal assessment of daily living skills, the patient achieved a standard score of 83.7, placing her performance in the <1st percentile and more than -1.0 standard deviation below the mean for her chronological age of 4 years and 2 months. This score represents a functional delay of greater than six months and substantiates significant difficulty with age-appropriate activities of daily living. She requires extensive caregiver assistance for dressing, utensil use during meals, and personal hygiene routines, which often result in behavioral meltdowns due to her underlying regulatory challenges, further increasing her dependence on adults.
The combination of significant, quantifiable delays in sensory processing, emotional regulation, social-play skills, and activities of daily living establishes a clear medical necessity for skilled occupational therapy intervention. These deficits comprehensively impair the patient’s functional independence, limit participation in the essential childhood occupations of play, learning, and self-care, and create safety concerns due to poor self-regulation and environmental awareness. Without skilled therapeutic intervention, the patient is at high risk for continued widening of developmental gaps, increasing social isolation, and persistent dependence on caregivers for basic functional tasks. Given the severity and pervasive nature of these deficits, impacting multiple domains of function, and the significant risk for further functional decline, ongoing occupational therapy is medically necessary. A frequency of two sessions per week is recommended to provide the intensity required to address her foundational sensory and regulatory needs, build essential social and self-care skills, and provide critical caregiver training to ensure carryover and promote meaningful progress toward age-appropriate independence.
| | Occupational Rehabilitation Potential: Good. with consistent Occupational Therapy and parental support | | Occupational Treatment Plan: Zaria is a 4-year, 2-month-old female who presents for an occupational therapy evaluation to determine her current level of function. Clinical findings from standardized assessment, informal observation, and caregiver report reveal significant delays across sensory processing, social-emotional development, and performance of activities of daily living, which adversely impact her functional participation in home and community environments. Throughout the evaluation, Zaria presented as highly distractible with poor cooperation, requiring numerous prompts to engage in structured tasks, which calls into question the reliability of standardized scores and suggests her functional deficits may be even greater than measured.
The patient demonstrates significant deficits in sensory processing and emotional regulation, with functional skills estimated to be delayed by more than twelve months, a level of performance consistent with scores falling more than -1.5 standard deviations below the mean. These challenges manifest as persistent sensory-seeking behaviors, such as crashing and jumping, and poor self-regulation, resulting in frequent emotional outbursts that are disproportionate to the situation. Her social and play skills are also substantially delayed, functioning at a level commensurate with a 24 to 30-month-old child, which reflects a quantifiable delay of 20-26 months and is consistent with performance greater than -2.0 standard deviations below the mean. Functionally, these core deficits in regulation and social interaction impede her ability to maintain attention for learning, follow directions in a preschool setting, and engage in cooperative, reciprocal play with peers, leading to social withdrawal.
These foundational deficits directly and negatively impact the patient’s independence in self-care. On the Roll Evaluation of Activities of Life (REAL), a formal assessment of daily living skills, the patient achieved a standard score of 83.7, placing her performance in the <1st percentile and more than -1.0 standard deviation below the mean for her chronological age of 4 years and 2 months. This score represents a functional delay of greater than six months and substantiates significant difficulty with age-appropriate activities of daily living. She requires extensive caregiver assistance for dressing, utensil use during meals, and personal hygiene routines, which often result in behavioral meltdowns due to her underlying regulatory challenges, further increasing her dependence on adults.
The combination of significant, quantifiable delays in sensory processing, emotional regulation, social-play skills, and activities of daily living establishes a clear medical necessity for skilled occupational therapy intervention. These deficits comprehensively impair the patient’s functional independence, limit participation in the essential childhood occupations of play, learning, and self-care, and create safety concerns due to poor self-regulation and environmental awareness. Without skilled therapeutic intervention, the patient is at high risk for continued widening of developmental gaps, increasing social isolation, and persistent dependence on caregivers for basic functional tasks. Given the severity and pervasive nature of these deficits, impacting multiple domains of function, and the significant risk for further functional decline, ongoing occupational therapy is medically necessary. A frequency of two sessions per week is recommended to provide the intensity required to address her foundational sensory and regulatory needs, build essential social and self-care skills, and provide critical caregiver training to ensure carryover and promote meaningful progress toward age-appropriate independence. | | Occupational Long Term Goals: | | Category | Goal Description | | Sensory Issues/Self Regulation | Within 6 months, through use of sensorimotor play, Zaria will initiate play with another person with minimal support in 4 out 5 opportunities to increase social interaction skills. Currently Zaria is requiring others to initiate play. | | Sensory Issues/Self Regulation | Within 6 months, Zaria will improve ability to self-regulate with minimal assistance to achieve an optimal state of arousal and alertness to complete a 3 minute functional activity 80% of the time. Currently Zaria is requiring max support for regulation and will attend to a task for a fe seconds. | | Self Care | Within 6 months, Zaria will pull pants up from knees to waist during dressing with no more than 3 verbal cues in 4/5 opportunities to increase independence in self-care. Currently Zaria is requiring max assistance to pull her pants up. | | Self Care | Within 6 months, Zaria will participate in putting on shoes by inserting feet and pulling shoes on with minimal assistance in 4/5 trials to increase independence with self-care skills. . |
| | Occupational Short Term Goals: | | Category | Goal Description | | Sensory Issues/Self Regulation | Within 3 months, through use of sensorimotor play, Zaria will initiate play with another person with moderate support in 3 out 5 opportunities to increase social interaction skills. Currently Zaria is requiring others to initiate play. | | Sensory Issues/Self Regulation | Within 3 months, Zaria will improve ability to self-regulate with moderate assistance to achieve an optimal state of arousal and alertness to complete a 2 minute functional activity 50% of the time. Currently Zaria is requiring max support for regulation and will attend to a task for a fe seconds. | | Self Care | Within 3 months, Zaria will pull pants up from knees to waist during dressing with moderate assistance in 3/5 opportunities to increase independence in self-care. Currently Zaria is requiring max assistance to pull her pants up. | | Self Care | Within 3 months, Zaria will participate in putting on shoes by inserting feet and pulling shoes on with moderate assistance in 3/5 trials to increase independence with self-care skills. |
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