Specific assessment results

1. Muscle tone, joint range of motion, and asymmetry

We have to consider factors that might be affected due to MyaGrace's cerebral palsy in this section. MyaGrace is able to use her right arm and hand voluntarily despite the mild high tone in her right arm and mild fisting of her right hand. She displays a difference between the right and left shoulders where her right shoulder is depressed more than her left. Since clapping requires use of both hands, this is a challenging activity for her. Specifically, MyaGrace’s right arm shows less movement than her left when bringing her arms to midline.

2. Reflex Development

MyaGrace’s reflexes appear typical, however this was not formally addressed at this time. The fact that she has mild cerebral palsy means she MAY have some difficulty, so we ill need to watch this as she grows.

3. Gross Motor Development

MyaGrace pulls to stand from sitting with help from mom or an object/furniture. She can stand independently for 1-2 seconds and crawls well. She has started cruising around furniture and can walk with one-hand support. She tends to “W” sit and when sitting with her legs in front she tends to sit on her lower back rather than on her buttocks.

4. Fine Motor Development

MyaGrace bangs two objects together at midline. She also rolls the ball back and forth to another person on the floor. MyaGrace can release objects with both hands, but tends to throw them. Mom reports that MyaGrace’s favorite toy is the stacking stars; she takes the stars off the ring. She shows a preference for her left hand, but will transfer objects from left to right. She activates toys by pushing buttons and uses pincer grasp with her right hand. MyaGrace can take objects out of a bucket, but will not put things into the bucket.

5. Self-help

MyaGrace takes her socks off and will help with dressing her upper body. Parents are concerned with MyaGrace’s feeding because she does not seem to be chewing her food. MyaGrace will drink from a sippy cup if someone is holding it for her and she will only drink from one particular cup at daycare. Mom reports that MyaGrace prefers to eat from a metal adult-sized spoon, however she was able to eat from a child size plastic spoon during the evaluation. She is able to feed herself with her hands by grasping the food with whole hand grasp, and she will use a spoon with some hand-over-hand assistance.

6. Social

MyaGrace is very social in familiar situations, and expresses hesitancy in unfamiliar situations. She is challenged by transitions, and overwhelmed by complex situations. MyaGrace can say dada, mama, hi, bubu, and ga (translation = singing). She will imitate nodding, shaking head, clapping, and banging blocks together. Mom reports that MyaGrace will cry or say “ah, ah, ah” if she wants you to play with her. IF mom does not respond immediately, she will slowly start to entertain herself.

7. Sensory

Since there were some questions whether sensory processing was a factor that interfered with MyaGrace's participation, the therapist had the parents complete the Infant/ Toddler Sensory Profile. See the sensory profile scores (This will open in a new window).

MyaGrace is exploring objects with a variety of textures with her hands and she will occasionally place objects in her mouth. Mom wants to know whether sensory concerns are part of the overall picture of her performance.

8. Factors the support participation

• MyaGrace has met many developmental milestones that indicate that she is making developmental progress . • MyaGrace seems to have an observant and supportive mother. • MyaGrace seems intereseted in interacting with others and with the environment. • MyaGrace is motivated to move despite some challenges in this area of development.

9. Factors that interfere with participation

• MyaGrace has some spasticity that makes moving more difficult. • MyaGrace has imbalances between the left and right sides of her body. • MyaGrace has social and self care milestones to meet so she can participate with peers and siblings.

10. What the findings mean for MyaGrace's participation.

* since parents are interested in MyaGrace improving her eating skills , we need to make sure to address this issue early in the intervention process. • Since MyaGrace is highly motivated to participate and interact with others, she is likely to respond well to a structured developmental program • Since MyaGrace’s spasticity and imbalance between right and left sides seems to slow her down, we need to identify strategies for making it easy for MyaGrace to interact with eating tools • Since MyaGrace has some motor slowness and incoordination, we need to provide fun opportunities to practice more times than usual so she can learn specific skills (e.g., grasping and releasing utensils and food items)