M.P is a 10-year-old Hispanic male who is a middle school student. He lives in 1 story house with his parents and a 6-year-old younger sister in Northwest Houston. M.P. was referred to occupational therapy service to address delayed milestone in childhood. His mother stated that M.P. has not yet demonstrated optimal occupational performance relating to fine motor skills, visual-motor skill, and self-care skills such as feeding and grooming. M.P.’s occupational history (provided by mother) reveals that he is a picky eater, and he avoids crunchy texture food. In addition, he does not like to perform grooming tasks such as combing his hair or brushing his teeth. M.P. stated that he loves to draw and he wants to master his …show more content…
values his role as a student in school and his role as a son in the family seriously. M.P.’s mother values pleasant family time during dinner. Both M.P. and his mother agree on the needs to improve M.P.'s fine motor skills, grooming skills, and for M.P. to eat food with various textures daily.
M.P.'s mother stated that her desired outcome of occupational therapy for M.P is to improve his eating habit and his handwriting skills.
Medical Information
M.P. was diagnosed with autism spectrum disorder. He was born at 37 weeks via cesarean section with breech presentation. He spent 2 days in NICU for monitoring and underwent tonsillectomy and adenoidectomy in 2014. His mother experienced preeclampsia during her pregnancy. M.P. is physically healthy; he has no known medication or food allergy.
Occupational Therapy Re-evaluation
M.P. was seen by OT for 6-month reassessment on 03/07/2016. Mother presented during re-evaluation. Standardized testing with BOT-2, clinical observation, and caregiver interview revealed that M.P.’ scores in fine motor precision, fine motor integration, manual dexterity, and upper limb coordination have increased since the initial evaluation , but his performances are still well below