In pediatrics, occupational therapy practitioners are concerned most with positively impacting the extent to which children and their families are able to successfully and meaningfully go about their daily lives, whether it be playing, learning, working, caring for oneself or others, or socializing.
Clinical decisions made throughout the evaluation process ultimately shape what and how occupational therapy practitioners deliver interventions, perhaps making the evaluation process the most important and interesting part of the service delivery process.
Gathering Relevant Background Information
The amount and type of available background information will vary tremendously from setting to setting. For example, in hospital settings, you will have the medical record to review, and in school settings, you may have a special education file to review if the student previously received special education services.
Common sources of pre-evaluation information include (1) medical records, (2) school records, (3) reports from other professionals (medical or educational personnel) who have seen the child, (4) interviews with parents or other caregivers, and (5) interviews with the referral source, teacher, or physician. Gathering information about the child’s diagnosis, presenting problems, and reasons for referral is essential before seeing the child.
Planning Your Evaluation
Selecting the assessment tools, materials, and activities that you will use during your evaluation. Three types of evaluation procedures are available: (1) administration of standardized assessment tools;
(2) nonstandardized but formal procedures, observations, and interviews; and
(3) informal observations, including naturalistic observations.
For most evaluations, you will probably use all three of these procedures.
Information on normal development is also important to consider in the evaluation planning process. This information helps you
(1) form appropriate and relevant interview questions,
(2) select appropriate toys and activities for the evaluation,
(3) gain insight into effective ways to approach children of various ages and developmental levels, and
(4) interpret the evaluation data.
Devising Evaluation Plans
Building Rapport, and Beginning Informal Observations
The first goal is to establish rapport with your clients (usually the child and a parent; in a school environment, this may be the teacher and child), and it is essential that you make them feel comfortable and that you are respectful.
From the moment you enter the child’s space or environment (e.g., home or classroom), take note of any specific characteristics that may have the potential to enhance or hinder the child’s performance. ? Begin to make informal observations of the child’s behavior, such as attention, affect, language use, activity level, and reactions to you as a stranger. Maximize their comfort level with the evaluation process.
Conducting Parent/Caregiver and Child Interviews
- Informal interviews with the child (children older than 3 or 4 years) and his or her parent(s) are helpful to gain information about the child’s interests, strengths, and challenges and will help you uncover child and family priorities.
- Child and family values, beliefs, and spirituality, which are included as client factors, are also commonly explored through interviews.
- Interview the child during the context of a play situation and while you are making informal observations.
- Set up the child with favorite toys near you and the parent(s) either at the end or at the beginning of the evaluation session while you speak with the parent(s).
- Explain to the parent ahead of time that you would like time to talk to them about their main concerns and priorities, and have them problem-solve with you about how this can take place.
Creating the Occupational Profile, Evaluating Occupational Performance and Performance Patterns
When using a top-down approach to evaluation, you begin by gathering information about the child’s ability to perform successfully in the roles and activities that are meaningful to him or her. Areas of Occupation such as ADL, education/ school-related activities, work activities (for older children), play, leisure, and social participation should be addressed.
Information about abilities to perform in valued areas of occupation may already be gathered from your interviews with the child and caregivers. Information about the child’s performance can also be acquired effectively through informal observations, particularly naturalistic observations. Various standardized assessment tools are also available for gathering evaluation data regarding a child’s functional abilities or occupational performance.
Standardized assessment tools also help direct your attention to the occupational areas giving a child the most difficulty, and the administration of these tools often initiates important discussions about the specific skills, tasks, and occupations most valued by the child or the caregivers.
Analysis of Occupational Performance: Evaluating Performance Skills and Client Factors
Performance skills are observable, goal-directed, behaviors that are necessary to engage successfully in one’s occupations, and they are categorized as:
(1) motor and praxis skills, such as bending, carrying, walking, sequencing and planning movements, manipulating objects;
(2) sensory and perceptual skills, such as recognizing familiar people, identifying a quarter by feeling in one’s coat pocket, hearing and understanding verbal directions, responding appropriately to a familiar sound, identifying food preferences based on taste;
(3) emotional regulation skills such as persisting when challenged, responding appropriately to the feelings of others, showing appropriate feelings of sadness or happiness, controlling anger, using calming strategies when stressed;
(4) cognitive skills such as organizing and prioritizing work, selecting necessary tools or materials for a task, using sound judgment, having adequate general knowledge; maintaining the necessary mental energy and focus to initiate and complete a task; and
(5) communication and social skills, including carrying on a conversation, developing a friendship, taking turns, sharing, and exchanging information
Evaluation of Motor and Praxis Skills
- Evaluation of neuro-musculoskeletal components includes assessment of muscle tone, reflexes, postural control and alignment, ROM, strength, and endurance.
- The motor components such as ROM and Manual Muscle Testing are observed informally, and their impact on functional skill performance is noted.
- Gross muscle testing might involve observing the child perform sit-ups, push-ups, and knee bends; noting their postural control during gross motor play; or asking the child to move his or her limbs or trunk against resistance.
- Physical endurance may be evaluated by noting a child’s physical tolerance for performing desired or necessary tasks or can be evaluated by noting the child’s postural control over time during the activity.
- Fine motor skills such as reaching, grasping, holding, manipulating, stirring, opening packages, and coordinating both hands together, are needed to perform most self-help skills.
- Standardized testing assists you by determining the aspects of fine motor performance or upper extremity functioning (client factors) that are most problematic (e.g., dexterity, visual-motor integration, eye-hand coordination, bilateral hand use, hand strength) and commonly provide you with a measure of the child’s performance in comparison with other children of the same or similar age.
- Client factors associated with fine motor skills include hand muscle strength, grip and pinch strength, dexterity, muscle tone, joint ROM, bilateral coordination, and visual-motor integration.
- Visual-motor integration refers to how the eyes and hands work together, and this function supports skills such as tracing, writing, using a computer, copying from a blackboard, using the hands for construction tasks like building with blocks, sewing, doing up buttons, etc.
- Despite no apparent neuro-musculoskeletal or sensory abnormalities, children with motor planning problems or dyspraxia often appear clumsy. Motor imitation of simple and gradually more complex body postures and motor sequences can also be conducted.
- Client factors that are believed to impact praxis abilities include cognition (ideation, planning, and sequencing), somatosensory, proprioceptive and vestibular sensory processing (discussed below), and neuro-musculoskeletal functions.
- Specific oral-motor skills to observe during feeding include opening the mouth in anticipation of food, lip closure, chewing, tongue mobility, cup drinking, sucking from a straw, and swallowing.
- Caregivers (and the child when applicable) should be questioned regarding the child’s oral-motor skills, diet, body weight, and nutritional concerns, food preferences, and ability to tolerate and manage various food textures and consistencies.
- Functions including swallowing, oral sensitivity, oral-motor reflexes, oral-motor control and coordination, the strength of the muscles around the face, and mouth should be evaluated along with tongue movements.
- Postural control factors such as muscle tone, trunk stability, head control, neck and trunk stability and movements, and sitting posture should be assessed because these factors influence oral-motor control.
Evaluation of Sensory-Perceptual Skills
Sensory-perceptual skills are defined in the OT Practice Framework as “actions or behaviors a client uses to locate, identify, and respond to sensations and to select, interpret, associate, organize and remember sensory events based on discriminating experiences through a variety of sensations that include visual, auditory, proprioceptive, tactile, olfactory, gustatory and vestibular”.
PROCEDURES FOR EVALUATING SENSORY AND PERCEPTUAL SKILLS AND FUNCTIONS
Evaluation of Cognitive Skills
Cognitive skills are defined in the OT Practice Framework as “actions or behaviors a client uses to plan and manage the performance of an activity”, such as being alert and aware of one’s surroundings, organizing and prioritizing work, and selecting necessary tools or materials for a task.
They are categorized as mental functions in the OT Practice Framework and include both specific and global mental functions. Specific mental functions include attention, memory, perception, thought processes, sequencing, and higher-level cognitive skills such as judgment, concept formation, cognitive flexibility, meta-cognition, and insight. Emotions, perception, one’s self-concept, and coping skills are also included as specific mental functions.
Global mental functions include consciousness/levels of arousal and awareness, orientation to person, place time and reality, temperament, emotional stability, personality, energy, motivation and drive, and the physiological process of sleep.
INFORMAL EVALUATION METHODS FOR ASSESSING COGNITIVE SKILLS IN INFANTS AND YOUNG CHILDREN
- Children with acquired brain injuries or severe and profound intellectual impairments require more formal evaluations of global mental functions. The Modified Glasgow Coma Scale for Infants and Children and Ranchos Levels of Cognitive Functioning are common assessment tools used to evaluate levels of consciousness/ arousal, orientation, and attention in children with acquired brain injuries.
- The Dynamic OT Cognitive Assessment is a standardized test that measures orientation, spatial perception, praxis, visuomotor organization, and thinking operations that can be used with children with acquired brain injuries, as well as with those with learning or other intellectual impairments.
Evaluation of Communication and Social Skills
Communication and social skills are defined in the OT Practice Framework as “actions or behaviors a person uses to communicate and interact with others in an interactive environment”. These include skills such as the ability to initiate and carrying on a conversation, maintain acceptable physical space when interacting with others, developing friendships, taking turns, sharing, and exchanging information through verbal exchanges, and being able to use appropriate facial expressions and gestures.
- Most developmental screening and evaluation tools, such as the Miller Assessment for Preschoolers, the Vineland Adaptive Behavior Scales, the Mullen Scales of Early Learning, and Bayley Scales of Infant Development, 3rd edition include test items, and/or separate scales that assess and measure communication, language, and social skills.
- For children not yet talking, note spontaneous verbalizations or sounds, and their use of communicative gestures (such as pointing, and waving bye-bye), and their ability to imitate sounds and simple words.
- For children who are speaking, note how easy it is to understand what they are saying (articulation), how many words they typically string together to construct phrases or sentences, and gather a general sense of their vocabulary. Also, determine the functional purposes of the language used, such as to get needs met, to share information and comment, to ask questions, etc.
- For children who use or may benefit from the use of augmentative communication devices, it is important for occupational therapists to analyze the demands (motor and cognitive) of operating a particular device and to determine whether the child has the necessary abilities to use the device practically and functionally.
Analysis of Occupational Performance: Evaluating Activity Demands, Environments, and Contexts
The analysis of occupational performance is a complex process that requires the consideration of activity demands, environments, and contexts in addition to the client factors, performance patterns, and performance skills.
- Activity demands are the part of your evaluation where you may perform a detailed activity analysis on specific tasks and activities associated with the occupations of the child you are evaluating. Sometimes activity demands can be easily modified to assist a child in being more capable of performing the activity or occupation. Therefore, considering interventions related to task modification or compensation as an approach may be most effective.
- COMPONENTS OF AN ACTIVITY ANALYSIS
Brief description of the activity
Objects used and their properties
Space demands
Social demands
Sequencing, timing, and patterns
Required skills/observable actions
Required body structures and functions
Safety hazards
Ways to adapt the activity
Ways to grade the activity
- Contextual/environmental evaluations are sometimes referred to more broadly as ecological evaluations. Ecological evaluations examine the interaction patterns, and fit between individuals and their respective environments, with consideration of physical, social, and cultural influences.
- Cultural contexts not only reflect one’s ethnic background, but values, norms, and expectations for behavior, such as a teacher’s classroom rules. In working with children and families, routines around feeding, bedtime, and other child-rearing practices.
- The physical environment includes accessibility factors such as obstacles in the environment that may hinder a child’s functional mobility, or limit maneuverability of assistive mobility devices, such as wheelchairs and walkers.
- The amount and type of visual, auditory, and tactile sensory stimulation or distractions that are apparent in the settings where the child is expected to concentrate and learn, should be noted.
- In examining preschool and other schools, or work settings, take note of how furniture is laid out, and how materials are organized and can be accessed.
- Finally, consideration of natural context provides the most direct, and practical information regarding how a child goes about their daily occupations, and how the quality of their performance is viewed by others.
Interpreting, Synthesizing, and Summarizing Your Evaluation Data
After your initial evaluation is complete, and you have scored and interpreted the standardized assessment tools that were administered, you need to synthesize and summarize all of your evaluation data.
SYNTHESIZING EVALUATION DATA FOR INTERVENTION PLANNING
Step One: Formulation of the occupational profile. Who is this child and what are important family characteristics? What are the main presenting problems? What are the primary occupations, including the child’s school program and extracurricular activities and interests?
Step Two: Identification of the child’s occupational strengths and challenges. What areas of occupation (e.g., activities of daily living, education, work, social participation, and play) are presenting challenges for this child? What does this child excel at?
Step Three: Identification of performance skills and child factors influencing occupational performance. What specific skills, body functions, and structures are interfering with or supporting the child’s ability to perform valued activities? Are you confident that the results of standardized tests reflect the child’s true abilities? How does your client’s performance compare with that of typical children or children with the same diagnostic condition? How does the child’s performance compare with his or her performance in previous evaluations?
Step Four: Identification of contextual factors and activity demands influencing occupational performance. How and where is the child expected to perform his or her daily activities, and under what conditions? What objects, skills, and actions are required for the child to perform his or her valued activities? What sociocultural factors impact the child’s occupational performance? What aspects of the physical environment support or hinder the child’s abilities?
Developing Recommendations and Intervention Planning
Developing an intervention plan considers the synthesis of your evaluation data, with the setting, service delivery system and program factors, and other practical considerations.
The intervention planning process includes the development of long-term goals and short-term, measurable objectives with selecting from various specific frames of reference and intervention techniques.
Some factors other than the assessment data that will need to be considered as we begin to make intervention planning decisions are the level of research evidence supporting the interventions that we are considering, client preferences, available equipment and materials, and our skill level.
For developmental milestones and reflex development, read our other blogs;
Read our other blog posts and follow us on Instagram.
Thank you for reading😊
