School-Based Pediatric OT Assessment

Client Name: Liam O'Connor

Assessment date: 14/05/2024

Main Reason for Referral

• Referred by Year 2 classroom teacher due to difficulties with handwriting legibility, fine motor endurance, and postural control at his desk.

Background Information

• 7yo male (DOB: 12/03/2017). PMHx: Mild Developmental Coordination Disorder (DCD) dx 2023. Nil regular meds. NDIS participant (No: 430-891-224). Lives with parents and 10yo sister. Unremarkable birth hx; slightly delayed motor milestones.

Current Functioning

• Independent in general school navigation and playground mobility. Exhibits rapid fatigue during tabletop tasks, resulting in task avoidance and disruptive classroom behaviours.

Self-Care

• Independent with toileting and basic feeding. Difficulty with fine motor fasteners (buttons, shoelaces) and opening tight lunchbox containers. Requires verbal prompting to pack schoolbag efficiently.

Motor Skills

• Gross motor: Mild core hypotonia; slumps in chair or wraps legs around chair legs for stability. Bilateral coordination slightly clumsy during ball skills.
• Fine motor: R-hand dominant. Uses an immature static tripod grasp with hyperextended DIP joints and excessive grip pressure. Decreased in-hand manipulation and intrinsic hand muscle endurance.

Self-Management

• Easily distracted by auditory and visual stimuli in the classroom. Seeks proprioceptive input (chewing on shirt collar, fidgeting, rocking in chair). Requires adult co-regulation to transition between high-energy play and quiet desk work.

Classroom/Learning

• Strong verbal comprehension and oral participation. Written output is slow and fatiguing. Poor letter formation, inconsistent sizing, and difficulty maintaining baseline alignment. Struggles to copy from the whiteboard efficiently due to slow visual-motor integration.

Social/Play Skills

• Friendly and well-liked by peers. Prefers unstructured gross motor play (chasey, climbing) over structured rules-based sports or tabletop board games. Engages well in imaginative play.

Communication Skills

• Receptive and expressive language WNL. Articulates needs clearly to teachers and peers, though occasionally talks to peers to avoid challenging fine motor tasks.

Main Areas of OT Focus

• Postural stability and seating ergonomics.
• Fine motor strength, grasp modulation, and handwriting fluency.
• Sensory regulation strategies to support classroom attention.

OT Goals

• Liam will utilise a functional dynamic tripod grasp with appropriate pencil pressure to write a 3-sentence paragraph with 80% legibility and baseline adherence within 6 months.
• Liam will independently select and use an approved sensory regulation tool (e.g., Move 'n' Sit cushion, Chewthelry, heavy work break) to maintain seated attention for a 15-minute instructional block within 1 term.
• Liam will independently manipulate lunchbox fasteners and jacket buttons without adult assistance within 1 term.