Myra Smith Beckler O.T.R.
Developmental Therapy Associates
4301 Markwood Lane
Fairfax, Virginia 22033

Occupational Therapy Evaluation

Name: Mark Hartmann
School: Ashburn Elementary, Loundoun County Public Schools
Grade: Roxanna and Joseph Hartmann
Address: 20751 LaPlume, Ashburn, VA
DOB: 8-21-85
Date of Evaluation: 6-9-94
Chronological Age: 8 years, 10 months

REASON FOR REFERRAL:

Mark was referred for an Occupational Therapy Evaluation by his parents for a second opinion due to concerns regarding educational placement issues. Mark is currently scheduled for occupational-Therapy services 2 times weekly for 30 minutes, along with support services of an educational assistant and speech and language pathology according to his individualized education plan.

HISTORY:

Mark, an autistic, non-verbal, pervasively developmentally delayed child has received speech and language pathology services, occupational therapy, adaptive physical education, social work consultation, psychological consultation and auditory training in previous educational settings according to past records and documentation to aid his inclusion. Mark has a large amount of background information that has been reviewed, with records indicating success with a facilitated communication approach to learning. Please refer to parental confidential files for past medical and educational reports.

GENERAL OBSERVATIONS:

Mark was observed during two one-hour testing sessions at home at his work table alone, and with his mother present. Verbal prompts and explanation of a reward system initially engaged Mark into testing items. Mark persisted with tasks for 5-10 minutes at a time. He would then, stand and run to the far end of the room and recline in a supine position until he was encouraged to return to the table. He occasionally pulled lightly at the examiner's cheeks, but would then return to testing items. At those times he received direct eye contact and positive support for a "good" job.

At the end of each testing he was given a break time. On the second testing session Mark independently followed the examiner to the work table and continued with the same routine for the second hour.

TESTS ADMINISTERED/CLINICAL OBSERVATIONS:
Developmental Test of Visual-Motor Integration:
Age Equivalent: 5 years 2 months
Percentile: 2%
Scaled score: 68

Motor Free Visual perception Test:
Perceptual Age: 4 years 9 months
Perceptual Quotient: 55


Peabody Developmental Motor Scales Fine Motor Section Clinical Observations:

The Peabody Developmental Motor Scales is an individually administered, standardized test that measures gross and fine motor skills of children from birth to 83 months. Clinical observations were made because this test could not be used in a standardized fashion due to Mark's age. On this test he demonstrated a scattering of skills from the 42 month level up to the 83 month level at an age equivalence of 54 months. Mark demonstrated a right handed preference for removing caps from bottles, stringing beads, winding a toy, cutting on a line and copying the word "STOP." Duplicating block designs was difficult in nature for Mark.

The Developmental Test of Visual Motor Integration is a developmental sequence of 24 geometric forms to be copied with paper and pencil. This tests samples of visual motor integration, the ability to visually perceive a stimulus, interpret it and direct the hand to duplicate the design. Motor planning and visual perception skills are essential components. This test is standardized on a population of normal children up to the age of 12 years 11 months. It requires the student to copy increasingly difficult two-dimensronal geometric shapes. This test suggests a visual motor age equivalent for Mark of 5 years 2 months. During the test Mark used a tripod of his right hand to draw horizontal, vertical and diagonal lines, circles, crosses, squares and x's. He attempted to draw a triangle and interconnecting geometric designs.

The Motor Free Visual Perception Test measures different aspects of visual perception, which is the brain's ability to interpret what the eye sees. This test requires the study to choose from alternatives presented in the test manual. There is no motor component, except pointing. This test assesses visual discrimination, visual memory, visual closure and visual form constancy. Mark's score suggested a perceptual age of 4 years 9 months.

NEUROSENSORY-MOTOR STATUS

Autism is associated with neurological impairment with developmental abnormalities of cell structure in the cerebellum and limbic regions of the brain. The limbic system is hypothesized to have a role in sensory modulation disorders. Sensory Integration procedures have been found most effective with children who over react to sensory stimuli. Sensory integration is a complex process of the nervous system. Through the integration of sensory information, a child perceives and registers information through a variety of sensory channels. Basic sensory channels, tactile, proprioceptive and vestibular begin to develop in utero and mature very early in childhood. Once these basic sensory systems are functioning efficiently, the next levels can develop upon this foundation. Organization of these sensations is needed to adapt automatically to environmental demands. Dysfunction in these sensory areas can be related to motor, academic or behavioral problems.

Because of an inability to process sensory input normally, the autistic child is often unpredictable. The child is uncertain about what adults want him or her to do, uncertain about how to go about it, uncertain what the adult's voice is saying or even which adult is speaking, uncertainty is anxiety producing. Often rhythmic activity helps to synchronize nervous system attending and suppress random, chaotic neuronal activity. This is one reason why Mark may swing, rock, chew on his shirt or hand and pace up and down. Autistic children need extra sensory input from their bodies in order to stay alert and focused. This input is often acquired through the vestibular-proprioceptive and tactile systems.

Autistic children have difficulty with even the most basic elements of communication. Mark demonstrated the ability to understand directions, and to complete tasks. When indicating his needs he would take the hand of the examiner or his mother and lead us to the items, using non-verbal communication.

The tactile sense is important for the development of· body scheme, for exploration of the environment and for motor planning. During the evaluation both clinical observations of being touched and reports from family indicated that Mark reacts to deep tactile input with a more organized response. He responds to light holding touch required for facilitated communication at his forearm and hand with a positive response. However, Mark demonstrates a dangerously high tactile threshold for high temperatures indicating an under-reaction to registering sensory input. According to his mother, all household faucets have been regulated so that Mark will not scald his skin.

The vestibular-proprioceptive system regulates his body posture, muscle tone, ocular motor control, balance and reflex integration. It also affects the development of bilateral integration and motor planning abilities. Muscle tone was found to be decreased in Mark's trunk and upper extremities. vestibular or movement based activities such as swinging appear to be one of his favorite activities. Balance was observed to be within functional limits as observed with walking up-down stairs and on uneven surfaces. In the area of fine motor control with writing, Mark held his pencil in a tripod position with opposition of the tips of the thumb, index and middle fingers for the fine localized movements needed for fluidity in duplicating designs. Mark exhibited jerky eye movements, sometimes loosing the target with visually tracking across the mid-line of his body and in horizontal and diagonal planes. Often eye movements were rapid suggesting that Mark guessed and missed some answers on the Motor Free Visual Perception Test. Though he was able to distinguish figures from a rival background accurately on a visual form constancy test.

SUMMARY:

Mark is a loveable young boy who is experiencing many difficulties in processing sensory information associated with neurological abnormalities typical of autism. Difficulties with modulation of sensory input are observed especially in the tactile, vestibular and proprioceptive systems. Mark has mastered many gross motor,·fine motor and visual perceptive tasks in spite of the effort and energy put forth to develop these skills. Mark's tactile system does not appear to'be well regulated, especially with temperature sensation. Mark has demonstrated the ability to understand directions, motor plan test items and to complete tasks. He uses non-verbal communication and gestures to indicate his needs. Testing results on a visual motor test at 5 years 2 months and on a visual perception test of 4 years 9 months are indicative of higher cognitive functioning.

RECOMMENDATIONS:

It is suggested that Mark receive Occupational Therapy 3-5 times weekly, integrated into the classroom for periods of 45 minutes using a sensory integration approach. Therapy should be carried out by a therapist skilled in sensory integration technique and with experience in relating these techniques to the home and to the classroom. It is suggested that therapy be part of an integrated program, consulting on a regular basis with parents and the entire team of those involved with Mark. Time is also needed to consult with teachers regarding visual motor and visual perceptive skills, the use of the computer in the classroom and making adaptive equipment or tools necessary to modify the environment for Mark to function effectively in the class. The following suggestions are made for the classroom teacher.

Mark would benefit from a classroom which provides a multisensory approach to learning and many opportunities for allowed experiential learning. He should be allowed frequent "breaks" to get up and move around. It would be helpful for him to have sufficient space of his own so he doesn't have to be concerned about the whereabouts of others. For example, if seated at a desk, he should not be near the door or pencil sharpener. Optimally, he should be placed in front of the room to offer him maximal visual and auditory cuing. When assembled in a group for story time, sharing, etc., he may benefit from sitting in a rocking chair, a bean bag chair or a space where he can lean against something, which would decrease the need to unconsciously attend to posture control and offer him a "safe space."

The use of facilitated communication has shown to be a successful substitute for written output. Varying vocal tone may help get his attention and eye contact. Also, whenever a new task is presented, it is important to be aware that Mark may experience difficulty. Hand over hand or hand at elbow assistance to give him the motor plan and kinesthetic feedback will help him process what is expected and help prevent frustration. However, if it is obvious that the tactile input is too threatening he may resist the assistance offered. Consistency in routine and teaching approach is critical for Mark.

Myra Smith Beckler, O.T.R.