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NORTHLAND COMMUNITY AND TECHNICAL COLLEGE

OCCUPATIONAL THERAPY ASSISTANT PROGRAM
Head Start Fine Motor Evaluation
Childs Name: Sophia
DOB: 05/18/11; 3 years 5 months and 11 days
DOE: 10/29/14
Location of Evaluation: Head Start, EGF, MN
Diagnosis: Unknown
Therapist: Abbey
Demographic Information/Reason for Referral/Background Information:
The head start teacher did not give any information about the child and did not express
any concerns about Sophias fine motor skills. Medical history was unavailable. Sophia
used her right hand for all of the coloring and writing activities.
Subjective:
Sophia mainly speaks Spanish and she understands some English but is still learning.
She was able to respond to simple questions with the use of one to two words or by
nodding her head.
Objective Information:
Physical Structure of the Hand:
Her hands appear to be physically normal in appearance and there are no deformities
present. There were no abnormalities seen within the joints and muscles of her hands.
With some effort she was able to take off the cap of a marker independently. She was
able to replace the marker cap independently.
Muscle Tone:
When feeling her hands, she had a normal muscle tone for her age because her hand
muscles were not too loose or too tight. Her arches are formed and still developing
because she could hold four standard size dice in each of her hands.
Range of Motion:
She successfully completed all of the upper extremity range of motions without any
difficulties. She completed shoulder flexion/extension, shoulder abduction/adduction,
elbow flexion/extension, wrist flexion/ extension, supination/pronation, finger
flexion/extension, finger abduction/adduction, thumb flexion/extension, and thumb
abduction/adduction.
Strength:
Grip Strength
Results
Right: 3lbs
Left: 2lbs
Posture/Balance:

Grip Norm
Comparison
(6-7 year old)
Right: 11.44lbs
Left: 9.97lbs

Pinch Strength
Results
Right: 3lbs
Left: 2lbs

Pinch Norm
Comparison
(6-7 year old)
Right: 2.3lbs
Left: 2.12lbs

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Here feet were aligned with her hips when standing, walking and running. She did not
demonstrate a loss of balance while sitting, standing, walking or running. Balance was
lost when she stood on one foot. She was able to lift foot two inches off of the floor for
two seconds. She did not understand what to do when she was told to close her eyes
while standing on one foot. Sophia had good posture during seated table activities but
would often change positions while sitting in chair. W-sitting was the childs preferred
way of sitting during story time.
Postural Adjustments during fine motor tasks:
She was able to keep her trunk still during fine motor tasks. During coloring and writing
activities she would move her shoulder and elbow joints verses using her wrist and finger
joint movements.
Coordination:
When coloring or writing, Sophia had consistent bilateral coordination. She was able to
hold onto the paper with her left hand while writing/drawing with her right hand. Sophia
had difficulty holding onto the scissors properly. She put her index and middle fingers in
the small hole on the top and her thumb in the bigger hole on the bottom. When
scissoring she also had difficulty holding on to the piece of paper she was cutting. She
would rip the paper while she was trying to cut it.
Attention to Task:
Sophia kept attention and was focused during the various tasks she completed. She did
not require redirection to the tasks. She visually attended the tasks by watching what
she was doing.
Emotional Reactions to Fine Motor Tasks:
Sophia did not become frustrated with any of the tasks. She was happy and content with
each of the activities presented to her. She did not get mad when she did not get an
activity right away. She initiated using the paper shape punchers during drawing time
but she was unable to push the puncher button independently. Sophia was willing to do
all of the tasks she was asked to perform.
Vision:
Sophia did not make much eye contact. She does not wear glasses. She was able to see
posters on the wall from a distance of seven feet. Eye convergence was present.
Sensory Reaction to Fine Motor Tasks:
Sophia used moderate and light pressure while completing the Beery VMI and during
drawing activities. She did not display any rough play. Sophia did not have any
discomfort with the lighting and colors that were present in the classroom. She showed
interest in the shape paper punchers during the craft activity and she explored them by
figuring out how they worked.
Development of Fine Motor Skills:
Sophia mainly used her right hand during activities. Sophia used the static tripod grasp
during the Beery VMI assessment and for drawing activities. She used a pincer grasp to
pick up dice, wooden beads, plastic chain links, and to hold on to a pipe cleaner. She was
able to successfully manipulate standard sized dice through translation to and from the

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palm of her hand. She was also able to shift the pencil she used to the appropriate spot
for writing and drawing. Sophia had difficulty holding onto the scissors properly. She put
her index and middle fingers in the small hole on the top and her thumb in the bigger
hole on the bottom. When scissoring she also had difficulty holding on to the piece of
paper she was cutting. She would rip the paper while she was trying to cut it.
Timing and Sequencing:
Sophia was able to successfully link pieces of a plastic chain together. She created two
bracelets for herself and she also started making a necklace but did not have enough
time to finish it. Sophia was also able to correctly string eight wooden beads onto a pipe
cleaner. She completed tasks in an appropriate amount of time and she did not rush
through them, she took her time and did a good job.
Quality of Movement:
Sophia displayed uncontrolled movements with using scissors as she was unable to
coordinate holding onto the paper and cutting at the same time. She was able to
alternate between supination and pronation while holding onto dice in her hands and
releasing them back into the container.
Finger Individuation:
Yes, she was able to control each finger individually but she preferred to use them as a
whole.
Pencil Grasp:
Sophia used a Static Tripod Grasp during handwriting and drawing activities. Her thumb
was in full opposition of her index finger, her pencil rested in her open web space, and
her arm and shoulder controlled the pencil and she had minimal finger movement.
Beery Visual Motor Assessment:
Raw Score
Standard
Score
Scaled
Score
Percentile

15
132
16
98

Assessment:
Sophia has normal muscle tone in her hands. Her overall hand strength is not very high
as observed by the OTAS she could not push the paper puncher button down
independently and required assistance from the OTAS. She has normal ROM in bother her
right and left UE. Taking off a marker cap required effort from Sophia but she was
eventually able to take off the cap independently. Sophia does not place her fingers in
the right holes on the scissor handles and she has difficulties with scissoring and
coordinating holding onto the paper and cutting simultaneously. Sophia has difficulty
with balancing on one foot with her eyes open. Sophia also shows difficulty with motor
planning which could eventually have an impact on her occupational performance.

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Sophia would benefit from skilled occupational therapy to work on fine motor
development, motor planning, pencil grasp, scissoring, balance and hand strengthening.
Plan:
Skilled occupational therapy is recommended 2x a week for 2 months to improve fine
motor development, motor planning, pencil grasp, scissoring, balance, and hand
strengthening.
Goals:
Sophia will independently cut across a 7 piece of paper with no more than 35 degrees
straying from straight line in one month.
Sophia will independently use a dynamic tripod grasp during most writing activities in 5
months.
Sophia will work on hand strengthening by finding objects in theraputty 3x a week.
Abigail Shamp OTAS
November 3, 2014