Occupational Therapy Progress Report for Child
Translated by
ScribdTranslationsOccupational Therapy Progress Report for Child
Translated by
ScribdTranslationsSERVICE REPORT
OCCUPATIONAL THERAPY
IDENTIFICATION
Nome:Ana Idade:2 anos
Data de Nascimento:23/09/2019 Responsible:
OBJECTIVE OF THE REPORT
Present evaluations and services regarding the child, considering the
seguintes queixas: atraso de fala, irritabilidade, olhar lateralizado, ecolalia e
difficulty in socialization.
The information in this report was provided by the parents and carried out the
clinical observation.
EVALUATION PROCEDURES
The occupational therapy sessions were held at
Clinic ------- with monitoring from March 11, 2022 until the
currently, 30-minute sessions are being held twice a week.
The instruments used for assessment and care were interviews.
with the parents, unstructured clinical observations, and approach to
psychomotor development.
OCCUPATIONAL THERAPEUTIC OBJECTIVES
I. Carry out activities that require your verbalization and communication;
II. Establishing a therapeutic bond to facilitate social interaction, such as the
direct eye contact with the therapist;
III. Organize behavior at the passive and active reaction levels;
IV. Stimulate the development of phonological awareness and guide the parents;
V. Stimulate the sensory-motor aspect.
CLINICAL EVALUATION AND OBSERVATION
On first contact, the child demonstrated independence while walking towards the
room, exploring the environment, showing interest in the toys
SERVICE REPORT
Occupational Therapy
presented and by the clinical environment. At first, the child presented
interest in animals and colors, shared toys, not presenting
difficulty in interacting with the therapist. restricted verbalization, stereotypies
verbal, unintelligible communication. The younger one does not show difficulty in interaction.
with other children, trying to socialize with another patient in the reception of the
clinic.
According to the observations, one can observe within the evaluations.
the following aspects were carried out:
Organization of Behavior:
Has the ability to initiate and imitate, responds to the commands of the therapist,
shows initiative when playing.
Motor- Postural:
Motor stereotypes, hand flapping, bionic hand. Intolerance in staying.
in activities that are not of your interest.
Space-environment relationship
Gradual increase in tolerance to the environment.
Social/Emotional
Accepts commands when performing activities. Shows irritability when
unable to perform the task, requesting help from the therapist to complete it.
Knows and performs social norms, such as hello and goodbye, apologizing and thanking.
Communication
Presents understandable communication, but at times
we observe vocal stereotypies, unintelligible verbalization.
Reassessment carried out in December 2022
Currently, the minor has completed the evaluation process of the VB-MAPP protocol.
where is the individual intervention program of the ABA method being carried out
Behavior Analysis developed by the Behavior Analyst, ABA supervisor.
SERVICE REPORT
Occupational Therapy
Organization of Behavior:
Shows greater acceptance with therapeutic environment, following in a way
Follow the commands and rules. Imitates assertively, presents
imaginary play.
Motor-Postural:
Exhibits regular motor development, demonstrates pincer grip for
pencil with coordination and strength accordingly.
Space-environment relation
There is a gradual increase in interest in activities that require
concentration and attention. It favorably carries out cognitive activities, such as
pairing, identifying, memory and reasoning.
Social/Emotional
The child has regular interactions with other children, exhibits a search.
visual and initiative for play, responds positively to activities
shared.
Communication
Significant gains in their communication were observed, but it is noted that
presence of verbal stereotypies and echolalic pattern frequently,
predominance of non-verbal communication.
FINAL CONSIDERATIONS:
Within the presented, the evaluative and intervention process was carried out,
seeking to break inappropriate behaviors, stimuli from functional play,
of expressiveness and reduction of stereotyped postural patterns. It was noted
SERVICE REPORT
Occupational Therapy
evolution in vocalization presenting vocal imitation with greater frequency and
assertiveness, greater acceptance for sensory activities, greater acceptance of
activities that do not involve your interest.
Parents and guardians receive specific guidance for adaptation of
routine, feedback from the services and stimulations that can be complemented
in the home environment, which favored its process of evolution.
It is directed to continue with the therapeutic intervention services.
ABA - Applied Behavior Analysis continuously, to provide a better
occupational performance to improve and maintain already achieved skills.
Sincerely,
___________________________________
Brenda
Occupational Therapist