The foundations for skills that are needed throughout life are established in early development. Pediatricians, the medical professionals who have the most frequent contact with children, are in a key position to identify developmental deviations in their patients. Early detection, along with intervention, has the potential to impact the child's life significantly and to effect changes that will cover the child's entire life span.
Pediatric occupational therapists (OT) and physical therapists (PT) help children achieve maximal functional independence in order to increase their children's participation in daily activities and routines in home, school, and the community. They support caregivers in order to ease the level of care often required for children with developmental disability, to enhance the children's learning opportunities, and promote the development of health and wellness in the growing years as a foundation for lifelong behaviors.1 Physical therapy is the provision of services to ameliorate, assess and treat mobility dysfunctions, and enhance physical health and functional ability throughout the lifespan.2 Pediatric physical therapists are experts in motor development, motor control, and functional mobility. They focus on motor development, facilitating mobility, and improving strength to enhance independence, function, and learning opportunities. Occupational therapy is the therapeutic use of everyday life activities (occupations) for the purpose of participation in roles and life situations in all settings. OT addresses the physical, cognitive, psychosocial, sensory, and other aspects of occupational performance in a variety of contexts to support engagement in activities that affect health, well being, and quality of life.3 The focus of occupational therapists is on children's ability to process sensory information and skillfully use their hands to perform typical life tasks such as self care, play, and school work.
Pediatric therapists use the World Health Organization Enablement Model4 because it presents the dimensions of disability in a positive light, emphasizing ability and participation rather than functional limitations and disability.5 Meaningful, functional results of treatment for children with developmental delay will not be achieved without recognizing the intimate relationship between the motor and sensory systems.
Pediatric occupational and physical therapists typically work with children from birth to 21 years. Children referred for therapy may have developmental disabilities noted at birth or at a very young age. Often, feeding difficulties are the first sign of developmental problems. These feeding problems may be structural in origin or arise from deficits in the motor or sensory systems. Other developmental problems may arise as the result of impairments acquired later in life, including traumatic injuries to the peripheral and/or the central nervous system, burns, cancers, etc. Some children, who may appear to be developing typically, present with delays as the child's life becomes more demanding and the child is expected to perform more complex tasks in school. They may have problems in attention, spatial relationships, cognition, and/or visual perception. Other difficulties detected may include clumsiness, trouble coordinating use of both sides of the body, and poor motor planning. Poor performance may be reported in school or at home in activities such as pedaling a tricycle, riding a bicycle, playing ball, playing with other children, and handwriting. Finally, other diseases with a genetic etiology, such as muscular dystrophy, may lead to delays and require intervention to support development, prevent deformity and sustain functional abilities, enabling the child to participate in activities within school, family, and community. Children in any of these categories, and their families, may benefit from OT and/or PT intervention.
Movement promotes cognitive and perceptual development, which together promote the development of functional performance.6 Increased or decreased muscle tone may limit the movement and sensory experiences that promote motor development. Sensory dysfunction might interfere with the infant's ability to play and learn. Pediatricians need to recognize behaviors that indicate the need for referral to a pediatric therapist for assessment. These behaviors can be seen during an office visit in the child's first year of life.
Figure 1. Control of flexion and midline orientation in a typical 6-month-old enables visually directed reach.
Figure 2. Excessive extension limits this 18-month-old girl from being able to reach accurately.
Commonly Used Tests and Measures
Figure 3. Forearm weight bearing in a typical 6-month-old enables weight shift to the side to free an arm for reach.
Figure 4. Compensations for weakness in an 1 8-month-old lead to use of excessive shoulder elevation and neck extension with reliance on locking joints and widely spread limbs.
In the first months of life, the infant develops postural control in prone and supine.7 As infants learn to move their bodies against gravity while lying on their backs, using flexion, they begin exploration of body parts and toys and the beginnings of eye-hand coordination.8 In the prone position, infants will develop the extension against gravity to support their heads and begin to take weight through their shoulders, which promotes the development of upper body control. As the infant is able to hold his head up, he is able to begin to explore his environment visually and begin to move his weight side to side to reach for toys. As infants lie on their sides to play, they begin to learn about sideward movement. While lying on their sides, they also learn to control flexion and extension, first coordinating activity to stabilize and roll as a unit, then to roll segmentally with trunk rotation. Then, in the sitting position, children practice and refine these skills to begin to move onto their hands and knees to expand exploration of the environment. With this increased postural control in sitting they are able to develop more refined hand skills. As control of their bodies improves, typically at 10 to 12 months, developing children begin to use a variety of sitting positions that prepare their trunks and legs to serve as support for the use of their hands. Pulling to stand and taking steps then follow.
Dysfunction in motor, vision, somatosensory, and/or vestibular systems may limit the child's ability to move through space for exploration. With disruptions in development, children use compensations, which most often inhibit the development of more advanced skills. It is important to note the child's ability to self regulate and to maintain a state of homeostasis. A child with the inability to do so may have difficulty adjusting and coping with any of a variety of changes in his environment and in developing relationships with others.9 The ability to engage in a play activity and to interact with reciprocity are the foundation for social relationship development.10
Motor compensations frequently seen include using neck hyperextension, shoulder elevation, and stiffening of the spinal extensors to support the body instead of controlling the activation of flexor and extensor muscles. Children with over and/or under sensory responsivity may avoid exploration or use rigid and controlling behaviors to control their environment. "The persistence of a small repertoire of movement behaviors limits the development of lower body control, including preparing the pelvis, hips, and legs for standing and walking. It may also limit the development of body awareness, praxis (motor planning), and visual perceptual skills. Lack of variability in movements frequently leads to the secondary impairments in the musculoskeletal and neuromuscular systems. Sidebar 1 (see page 486) describes atypical behaviors that serve as red flags. Figures 1 through 9b (pages 486 through 492) show typical and abnormal positioning in various childhood stages of development.
REFERRALS: TO WHOM? FOR HOW LONG?
Laws and regulations with respect to therapy referrals vary from state to state. Licensed therapists are aware of the requirements in their own state and are responsible for ensuring that referrals are in compliance with local regulations. When referring a child for therapy it is important to include medical diagnoses, reason for referral, pediatrician's specific concerns, and precautions. A child may be referred for either occupational or physical therapy or both depending on the child's needs and family's concerns. Many children with developmental disability require both services because deficits typically affect all areas of function. When both services are not indicated, not available, or unable to be provided because of limited family or community resources, it is necessary to select the most appropriate intervention. If the primary problems are in motor function, including gait dysfunction, limitations in range of motion and/or strength, or problems related to cardiopulmonary or respiratory function, a referral to PT is appropriate. Main deficits in functional performance, sensory processing, visual perception, and/ or fine motor skills suggest a referral to OT. Referrals are typically written, requesting an evaluation and treatment. After the child is evaluated, best practice calls for communication between the therapist(s) and the referring pediatrician. A treatment plan is then developed through collaboration between clinicians and the family. The plan should address expected outcomes, frequency, and duration of therapy.
Intervention may continue throughout the child's life from infancy through school age and into adulthood, may be intermittent, or may be provided for a short term. The need for treatment will depend on the severity of impairments and the impact on development. Ongoing assessment of the child's function will guide any needed modifications of interventions.
Figure 5.This 10-month-old girl is able to use a variety of sitting positions to refine the use of her hands to explore her environment.
Figure 6. This 18-month-old sits only in this position to compensate for weakness and has developed secondary limitations in joint mobility.
Common Treatment Interventions for Children with Developmental Disability and Resources Available to Pediatricians and Families
An evaluation determines the need for therapeutic intervention and leads to the development of a treatment plan. Evaluation is a clinical judgment made by a uherapist based on data gathered from an examination.12 Components include the following:
* Review: child's medical and family history; educational setting; social activities; cultural background; daily routines; and adaptive equipment * Functional abilities and occupational performance: mobility, activities of daily living, play, and social participation.
* Functional limitations and participation restrictions.
* Posture and Movement Analysis (how the child moves):13 alignment, postural control and balance, weight shifts, movement strategies/compensations, symmetry/asymmetry, coordination, and discipline specific analyses including gait,14 handwriting.
* Systems Analysis: assess interaction of body functions and structures in order to determine impairments that cause limitations.
Systems include the following:
* Behavior/self regulation: Arousal, state regulation, orientation and modulation of attention and interest, interpersonal interactions, appropriateness of emotional/behavioral responses
* Sensory: Visual, auditory, vestibular, somatosensory, lack of innervations, decreased sensory awareness and registration, sensory modulation (being defensive or avoidant), sensory processing (difficulty being able to use sensory information in order to perform purposeful, skilled movement),15 body awareness
* Neuromuscular: Tonal abnormalities, stiffness, poor coordination, excessive or prolonged muscle firing, poor ability of muscles to work together, reflexes
* Musculoskeletal: limitations in passive or active movement, muscle extensibility, skeletal abnormalities, strength
* Respiratory: Rate, patterns, breath control, capacity
* Perceptual/Cognitive: Intelligence, memory, executive functions, judgment, safety, adaptability to environment/tasks, spatial orientation, visual perceptual, motor planning
* Cardiovascular: Edema, peripheral circulation, skin color, temperature
* Integumentary (Skin): Integrity, color, extensibility
Tests and measures
Pediatricians may receive evaluation reports with results from one or more of the tests listed in Table 1 (see page 487). Requirements for specific standardized tests to determine eligibility for services vary in each state and locality. Formal measures are child-centered and may be criterion or norm-referenced. They are usually done at regular intervals, ranging from weekly to yearly. Informal measures are also childcentered and use non-standardized instruments, checklists, developmental skill level forms, and interviews. Ecologically based measures assess functional activity performance of the child within the environment. They take into consideration the physical environment, social interaction and psychological status of the child. Behavior is described across domains, and the adaptability of the child is noted. These include anecdotal records, clinical ratings, and inventories and are typically done on an ongoing basis across environments.
Analysis of the information gathered enables the therapist to determine needs, consider interventions and make recommendations. Therapists work with the family to set priorities and develop a plan. When therapy is indicated, an occupational and/or physical therapy treatment plan is developed to meet the individual needs of the child and family. Short- and long-term goals/outcomes must be functional, measurable, objective, and specific to the child.
Figure 7.This 4.5-year-old boy with increased tone relies on his arms for support and cannot use his hands to play when sitting on the floor.
Figure 8. At 13 months, this child has developed sufficient postural control and alignment to move through space in all directions.
Additionally, the therapist may make a variety of specific recommendations. These can include durable medical equipment and assistive devices specifically designed to meet each child's needs, therapist fabrication of hand and foot splints, and suggestions for other related services and school placement.
The purpose of intervention is to maximize the child's functional abilities and per-0 formance in daily life by developing strengths, improving skills, decreasing or minimizing impairments and preventing secondary impairments from developing. Occupational and physical therapists work in a variety of settings. In all settings, the therapist may provide direct or indirect intervention.
Direct intervention includes individual or group treatment by a therapist, collaboration with other professionals involved in the child's life, and instruction to caregivers to integrate treatment activities into the child's daily life. Building on strengths of the child and the family is important for successful intervention. Training the family in home programs to integrate treatment outcomes into daily functional activities is essential. Home programs may include instructions for the caregiver to assist the child in daily routines such as dressing and feeding to improve postural control, improve range of motion, and enhance movement and coordination in a child with neuromuscular and musculoskeletal impairments. Home programs including specific sensory activities, and structured routines may help a child with autism or a sensory processing disorder to be able to function within his environment.16
Figure 9a. Excessive extension prevents this 18-month-old girl from standing erect on flat feet to begin walking.
Figure 9b. With therapist-fabricated ankle-foot splints, she is able to stand upright and begin to learn to take steps.
Indirect intervention includes therapists' consultation and recommendations. Consultation with the family, teachers, and other professionals working with the child guides activities to improve functional performance. Therapist recommendations may include appropriate placement in school and community activities, specific interventions carried out by others and monitored regularly, specialized assistive devices, and adaptations to the environment.
Assistive technology (AT) refers to any device that is used to help an individual perform some task of daily living. These may be homemade, purchased commercially, modified, fabricated by a therapist, or medically prescribed. Special switches can help a child with cerebral palsy activate a toy for play or use a computer. A pencil grip can improve handwriting; a buttonhook can help children with hemiplegia or a brachial plexus injury dress and undress by themselves. Sidebar 2 (see page 492) gives examples of AT devices commonly used by OTs and PTs.
Adaptations of the child's environment include changes at home, school, or in the community to allow a child who uses a wheelchair to participate in all areas of family and community life with access to the bathroom, the playground, community buildings, and transportation. Adaptation of the environment for a child with difficulty processing sensory information may be to decrease visual, auditory or tactile distractions in a classroom or at home. This may mean changing the location of their seat in the classroom, creating a quiet, calm area for reorganization, and/or buying clothes without seams or cloth that irritates.
There are many specific treatment interventions used by pediatric therapists. Selecting an appropriate approach, skillful implementation, and assessment of effectiveness is key to successful therapy. Intervention should be child-driven and in the context of play and other functional activities. In order to ensure an optimum level of care, therapists endeavor to use evidence-based practice. Integrating available research, clinical expertise, and family values drives clinical decision making. It is important to appreciate the need for more and better evidence for any particular treatment technique and to use outcome measures specific for each child to assess treatment effectiveness and planning. Assessment is ongoing throughout intervention, and treatment becomes a dynamic process that changes and evolves with the needs of the child and family.
Table 2 (see page 490) lists common treatment interventions for children with developmental disability and resources available to pediatricians and families.
Pediatricians are often the first professionals to detect signs of developmental delay in young children. Early detection and prompt intervention are essential to maximize the child's development, abilities, and performance. Knowing to whom, when, and where to refer patients and what to expect from occupational and physical therapists will ease the child's care and ensure the best possible outcome.
1. www.pediatricapta.org/graphics/ Gen%20Ped%20PT.pdf. Accessed April 15. 2007.
2. www.apta.org/AM/Template.cfm7Section= Horae&TEMPLATE=/CM/ContentDisplay. cfm&CONTENTID=32269. Accessed April 15, 2007
3. American Occupational Therapy Association. Definition of OT practice for the AOTA Model Practice Act: Representative Assembly proposed business agenda, part I. OT Practice. 2004;9(5):22-34.
4. World Health Organization. International Classification of Functional Disability and Health. Geneva: World Health Organization; 2001.
5. Goldstein DN, Cohn E, Coster W. Enhancing participation for children with disabilities: application of the ICF enablement framework to pediatric physical therapist practice. Pediatr Phys Iter. 2004:16(2): 1 14-120.
6. Campbell SK. The child's development of functional movement. In: Campbell SK, Vender Linden DW, Pausano RJ, eds. Physical Therapy for Children, 3rd ed. St Louis, MO: Saunders Elsevier, 2006:33-76.
7. Bly M. Motor Skills Acquisition in the First Year of Life. San Antonio, TX: Therapy Skill Builders (a division of The Psychological Corporation); 1994.
8. Erhart RP, Duckman RH. Visual-PerceptualMotor Dysfunction and Its Effects on Eye-Hand Coordination and Skill Development Functional Visual Behavior in Children: An Occupational Therapy Guide to Evaluation and Treatment Options, 2nd ed. Bethesda, MD: American Occupational Therapy Assoriation;2005:171-228.
9. Williamson G, Szczepanski M. Coping Frame of Reference. Frames of Reference for Pediatric Occupational Therapy, 2nd ed. Lippincott Williams & Wilkins; Baltimore, MD: 1999;43 1-468.
10. Case-Smith J. Bryan T. The effects of occupational therapy with sensory integration emphasis on preschool-age children with autism. Am J OccupTher. 1999;53(5):489-497.
11. Miller LI, Anzalone ME, Lane SJ, Cermak SA, Osten ET. Concept Evolution in Sensory Integration: A Proposed Nosology for Diagnosis. Am J Occup Ther. 2007:61: 135-140.
12. American Physical Therapy Association. Guide to physical therapist practice, 2nd ed. Phys Ther. 2001;81(1):S19-S28.
13. Howie JM. Neuro-Devebpmental Treatment Approach: Theoretical Foundations and Principles of Clinical Practice. Laguna Beach, CA: NeuroDevelopmental Treatment Association; 2002.
14. Stout JL. Gait Development and Analysis. In: Campbell SK, Vander Linden DW, Pausano RJ, eds. Physical Therapy for Children, 3rd ed. St. Louis, MO: Saunders Elsevier, 2006:161-190.
15. Miller U, Coll JR, Schoen SA. A Randomized Controlled Pilot Study of the Effectiveness of Occupational Therapy for Children With Sensory Modulation Disorder. Am J Occup Ther. 2007;61:228-238.
16. Miller LJ. Sensational Kids: Hope and Help for Children with Sensory Processing Disorder (SPD). New York: G.P. Putnam Sons; 2006.
Commonly Used Tests and Measures
Common Treatment Interventions for Children with Developmental Disability and Resources Available to Pediatricians and Families