PEDIATRIC THERAPY

An Interprofessional Framework for Practice

PEDIATRIC THERAPY
An Interprofessional Framework for Practice

Editor
Catherine Rush Thompson, PT, PhD, MS
Professor of Physical Therapy
Physical Therapy Education
Rockhurst University
Kansas City, Missouri

Associate Editors

Ketti Johnson Coffelt, OTD, MS, OTR/L

Assistant Professor of Occupational Therapy
Rockhurst University
Kansas City, Missouri

Pamela Hart, PhD, CCC-SLP

Associate Professor of Communication Sciences and Disorders
Rockhurst University
Kansas City, Missouri
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All contributing authors to this book have no financial interests in any resources shared in this book. All therapists are clini-
cians and/or academicians who hope to add to the body of knowledge in pediatric therapy.

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Library of Congress Cataloging-in-Publication Data

Names: Thompson, Catherine Rush, 1954- editor. | Coffelt, Ketti Johnson,

editor. | Hart, Pamela (Associate professor of communication sciences and
disorders), editor.
Title: Pediatric therapy : an interprofessional framework for practice /
editor, Catherine Rush Thompson ; associate editors, Ketti Johnson
Coffelt, Pamela Hart.
Other titles: Pediatric therapy (Thompson)
Description: Thorofare, NJ : SLACK Incorporated, [2018] | Includes
bibliographical references and index.
Identifiers: LCCN 2018000340 (print) | LCCN 2018000721 (ebook) | ISBN
9781630911782 (Epub) | ISBN 9781630911690 (Web) | ISBN 9781630911775
(paperback : alk. paper)
Subjects: | MESH: Pediatrics--methods | Interprofessional Relations |
Intersectoral Collaboration | Cooperative Behavior | Clinical Competence |
Child | Adolescent | Infant
Classification: LCC RJ499.3 (ebook) | LCC RJ499.3 (print) | NLM WS 366 | DDC
618.92/89--dc23
LC record available at https://lccn.loc.gov/2018000340

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 DEDICATION

“I wanted a perfect ending. Now I’ve learned, the hard way, that
some poems don’t rhyme, and some stories don’t have a clear beginning,
middle, and end. Life is about not knowing, having to change,
taking the movement and making the best of it,
without knowing what’s going to happen next.
Delicious Ambiguity.”
—Gilda Radner

We dedicate this book to our own families who have provided support in our professional and personal lives, to our
students who have asked the challenging questions that explore ambiguity and inspire critical thinking, to our colleagues
who have shared their professional expertise, and, most importantly, to those families who have inspired us and trusted us
with their children’s care. It has been a privilege to learn and to grow together.
 CONTENTS
Dedication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .v
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix
About the Primary Editor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi
About the Associate Editors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii
Contributing Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xv
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xvii

Section 1 Interprofessional Approaches to Pediatric Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Catherine Rush Thompson, PT, PhD, MS and Pamela Hart, PhD, CCC-SLP

Section 2 Interprofessional Frameworks of Pediatric Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

Catherine Rush Thompson, PT, PhD, MS;
Pamela Hart, PhD, CCC-SLP; and Ketti Johnson Coffelt, OTD, MS, OTR/L

Section 3 Culturally Competent Pediatric Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Catherine Rush Thompson, PT, PhD, MS

Section 4 Overview of Human Growth and Development for Pediatric Therapists . . . . . . . . . . . . . . . . . . . . 43

Catherine Rush Thompson, PT, PhD, MS

Section 5 Interprofessional Management of Pediatric Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71

Catherine Rush Thompson, PT, PhD, MS and Grace McConnell, PhD, CCC-SLP

Section 6 Interprofessional Care of High-Risk Infants. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85

Pamela Hart, PhD, CCC-SLP; Carol Koch, EdD, CCC-SLP; and
Catherine Rush Thompson, PT, PhD, MS

Section 7 Teamwork in Early Intervention. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .101

Catherine Rush Thompson, PT, PhD, MS and Lauren Little, PhD, OTR/L

Section 8 Working With Families of Young Children With Special Needs . . . . . . . . . . . . . . . . . . . . . . . . . . .115
Ketti Johnson Coffelt, OTD, MS, OTR/L and Catherine Rush Thompson, PT, PhD, MS

Section 9 Providing Support for Children 5 to 21 Years in the Educational Setting . . . . . . . . . . . . . . . . . . . 133
Joan Delahunt, OTD, MS, OTR/L; Mildred Oligbo, PT, DPT;
Pamela Hart, PhD, CCC-SLP; and Catherine Rush Thompson, PT, PhD, MS

Section 10 Providing Interprofessional Medical Care for Children and Adolescents . . . . . . . . . . . . . . . . . . . . .149
Brandi Dorton, DPT; Stephanie Orr, PT, DPT, PCS; Joan Delahunt, OTD, MS, OTR/L;
Lynn Drazinski, MA, CCC-SLP; and Catherine Rush Thompson, PT, PhD, MS

Appendix A Interprofessional Engagement With Children: Testing Developmental Reflexes . . . . . . . . . . . . . . .165

Catherine Rush Thompson, PT, PhD, MS

Appendix B Interprofessional Communication: Selecting Tests and Measures . . . . . . . . . . . . . . . . . . . . . . . . . .173

Catherine Rush Thompson, PT, PhD, MS

Appendix C Interprofessional Collaboration: Wheelchair and Seating Evaluation . . . . . . . . . . . . . . . . . . . . . . . .181

Catherine Rush Thompson, PT, PhD, MS
viii Contents

Appendix D Pediatric Professional Role Play: A Case for Assistive Technology . . . . . . . . . . . . . . . . . . . . . . . . . .183
Pamela Hart, PhD, CCC-SLP

Appendix E Evaluating and Using Professional Websites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189

Catherine Rush Thompson, PT, PhD, MS

Appendix F Educational Resources: Videos and Books Related to Pediatric Therapy . . . . . . . . . . . . . . . . . . . . .191
Catherine Rush Thompson, PT, PhD, MS
 ACKNOWLEDGMENTS

“Alone we can do so little; together we can do so much.”

—Helen Keller

We would personally like to thank our professional colleagues who have supported this effort and provided valuable
insight regarding the importance of interprofessionalism for pediatric therapists. More specifically, we would like to thank
those who contributed their time and effort to this book through authoring and reviewing the book’s contents for accuracy
and relevance. We are also indebted to family members, friends, students, and families who provided an incentive for devel-
oping a manual promoting interprofessional care for children and their families.
 ABOUT THE PRIMARY EDITOR

Catherine Rush Thompson, PT, PhD, MS is a professor in the Department of Physical Therapy Education at Rockhurst
University in Kansas City, Missouri, and a consultant for Community Living Opportunities—helping individuals with
developmental disabilities achieve fulfilling lives in the community. Her pediatric therapy experience spans over 40 years,
including owning a private practice and working alongside pediatric professionals serving pediatric populations and their
families. Catherine has practiced in early intervention, home-based therapy, and educational, medical, and community-
based settings, offering screenings and child- and family-centered care to infants, children, adolescents, adults, and older
adults with and without developmental disabilities and other health care needs. With research and teaching experience in
health promotion, pediatrics, motor imagery, neurorehabilitation, professional development, and clinical decision making,
as well as interprofessional service in Ecuador, Guatemala, Haiti, and Kyrgyzstan, she brings a deep appreciation of interpro-
fessional collaboration and cultural competency for providing high-quality care to all communities. Her most recent publi-
cation, Prevention Practice and Health Promotion: A Health Care Professional’s Guide to Health, Fitness, and Wellness, Second
Edition, addresses health care issues across the lifespan and emphasizes holistic care. She hopes that Pediatric Therapy: An
Interprofessional Framework for Practice will provide a foundation for engaging students and clinicians in interprofessional
discussions and activities that will enhance the quality of care in pediatrics.
 ABOUT THE ASSOCIATE EDITORS

Ketti Johnson Coffelt, OTD, MS, OTR/L is a professor in the Department of Occupational Therapy Education at
Rockhurst University and an occupational therapist for the Olathe School District, providing consultative services with
students receiving extensive homebound services due to medically related variables. She has over 28 years of experience as
an occupational therapist, working primarily in pediatrics and school systems. She has served on many school teams as a
team member and as a facilitator, developing and implementing student Individualized Education Programs (IEPs), mentor-
ing team members, and participating in collaborative consultation with other educational professionals. She saw firsthand
the value of forming effective preschool- and school-age early intervention teams with other professionals and families to
facilitate a shared partnership and commitment to meeting each child’s ever-changing learning needs. Her collaborative
teaming experiences bring a depth of understanding of the opportunities and challenges of the interprofessional team col-
laborative process used to support children and youth learning. Her research endeavors include a peer-reviewed publication,
Continuing Competence Trends of Occupational Therapy Practitioner, and critical appraisal of the effectiveness of visual task
sequencing in the establishment of skills and routines of children with disabilities. She has presented at regional and national
professional occupational therapy conferences, with research focused on the use of video modeling with tasks in the home
environment for children and adults with disabilities and on exploring the sensory-adaptive approach of pressure undergar-
ments for children with attention deficit/hyperactivity disorder.

Pamela Hart, PhD, CCC-SLP is an associate professor in the Department of Communication Sciences and Disorders
at Rockhurst University. She teaches and conducts research in the areas of augmentative and alternative communication,
autism spectrum disorders, research methods, and child language disorders. Of specific interest to Dr. Hart is the qualita-
tive study of the ways that rehabilitation and educational teams work together to provide interdisciplinary services to clients
with complex communication needs to support language and literacy development. She has numerous national and regional
presentations and publications related to this topic. Clinically, Dr. Hart provides speech-language pathology services as
part of an interdisciplinary team that evaluates and implements treatments for individuals who are nonverbal and require
augmentative and alternative communication strategies. She has many years of experience working alongside occupational
therapists, physical therapists, educators, and others with the goal of helping individuals with complex needs to meet their
highest potential. The combination of Dr. Hart’s research interests and clinical experiences provide a strong basis for the
concepts presented in this book. Her publications and presentations include, but are not limited to, effective teaming, facili-
tation of language with clients using augmentative and alternative communication, play and technology in early childhood,
assistive technology for literacy interventions, interventions for children with complex communication needs and physical
impairments, educational placement decisions for children with complex communication needs, and improving graduate
students’ skills and confidence through structured lab experiences. She brings a wealth of clinical and educational experi-
ence to her writing.
 CONTRIBUTING AUTHORS

Joan Delahunt, OTD, MS, OTR/L (Sections 9 & 10) Lauren Little, PhD, OTR/L (Section 7)
Assistant Professor of Occupational Therapy Assistant Professor
Rockhurst University Department of Occupation Therapy
Kansas City, Missouri Rush University
Chicago, Illinois
Brandi Dorton, DPT (Section 10)
Physical Therapist Grace McConnell, PhD, CCC-SLP (Section 5)
Physical and Occupational Therapy Assistant Professor of
Children’s Mercy Hospital Communication Sciences and Disorders
Kansas City, Missouri Rockhurst University
Kansas City, Missouri
Lynn Drazinski, MA, CCC-SLP (Section 10)
Professional Faculty Mildred Oligbo, PT, DPT (Section 9)
Communication Sciences and Disorders Clinical Assistant Professor of Physical Therapy
Augustana College University of Kansas Medical Center
Rock Island, Illinois Kansas City, Kansas

Carol Koch, EdD, CCC-SLP (Section 6) Stephanie Orr, PT, DPT, PCS (Section 10)
Associate Professor of Communication Sciences and Physical Therapist
Disorders Pediatric Certified Specialist
Samford University Physical and Occupational Therapy
Birmingham, Alabama Children’s Mercy Hospital
Kansas City, Missouri
 PREFACE

“Interprofessional education is a collaborative approach to develop healthcare students as future interprofessional team
members and a recommendation suggested by the Institute of Medicine. Complex medical issues can be best addressed by
interprofessional teams. Training future healthcare providers to work in such teams will help facilitate this model resulting in
improved healthcare outcomes for patients.”1

This book is designed to engage clinicians and students in interprofessional learning experiences that cultivate collabora-
tive practice and optimize the outcomes of those served. According to the American Speech-Language-Hearing Association,
“There is a growing emphasis on interprofessional education in health care as a result of research demonstrating the benefits
of interprofessional collaborations in health care that require continuous interaction, coordinated efforts, and knowledge
sharing among healthcare professionals.”2 These ongoing interprofessional interactions are especially important for pediatric
therapists serving families whose children are dynamically growing and developing new skills.
Pediatric therapies typically include physical therapy, occupational therapy, and speech-language pathology. Other valu-
able team members include family members, medical and nursing staff, special educators, case workers, and others engaged
in a child’s care and education.
When working with families and other professionals and paraprofessionals, all team members benefit from competency
in key pediatric skills, whether services are provided in the classroom, clinic, school, or community. Common foundational
knowledge across all disciplines includes2-7:
• Recognizing philosophies and frameworks underlying pediatric care (eg, child- and family-centered care)
• Screening for typical growth and development
• Assessing the abilities of infants, children, youth, and adolescents in various situations
• Performing standardized and criterion-referenced tests and measures of infants, children, youth, and adolescents
• Recognizing legal and ethical issues impacting pediatric care
• Addressing unique issues related to specific practice settings
• Using the clinical reasoning process for designing and modifying interventions
• Implementing evidence-based practice
This manual will provide learners across disciplines with learning experiences emphasizing foundational knowledge and
essential skills for effective interprofessional collaboration in pediatric settings. These skills include3-9:
• Recognizing typical and atypical development of children from birth to adulthood
• Realizing the importance of holistic care
• Respecting the roles, frames of reference, and approaches favored by each discipline
• Providing services within the scope of practice determined by professional and legal standards
• Developing essential skills for interprofessional care to improve health care and educational outcomes for children and
their families
Each section of this manual offers learning objectives, key concepts, and case-based learning activities requiring integra-
tion of information and critical reasoning. The appendices offer additional opportunities for interprofessional engagement.
Common pediatric conditions discussed in this manual include autism spectrum disorder, cerebral palsy, developmental
delay (including children “at risk” for developmental delay), Down syndrome, and other common health impairments.
Although this manual does not outline specific pediatric pathologies and their discipline-specific management, it encour-
ages learners to explore current evidence-based literature to understand the most recent developments related to pediatric
pathologies and their management. Using interprofessional skills, professionals can embrace their distinctive roles in
 xviii Preface

pediatric care while sharing theoretical frameworks and therapeutic approaches across practice settings. The ultimate goal
is to improve the child’s and family’s quality of life.
Upon completion of this manual, learners should be able to demonstrate the following interprofessional skills:
• Discuss the roles and responsibilities of professionals providing pediatric care
• Describe family-centered, routine-based care and its importance in healthy growth and development
• Differentiate pediatric care provided in the home, schools, and medical settings
• Select valid and reliable tests and measures of growth and development of infants, toddlers, youth, and adolescents
• Collaborate with others in the development of goals and evidence-based pediatric interventions
• Select and design appropriate interprofessional interventions for children with special needs and their caregivers
• Educate others about preventive care for healthy growth and development
• Discuss current, evidence-based resources for children, their families, and others
• Engage in interprofessional clinical reasoning to address common problems faced in dynamic pediatric practice
Overall, this manual is designed to offer learners a guide for developing interprofessional competencies needed in pedi-
atric therapeutic practice settings.

REFERENCES
1. Bridges DR, Davidson RA, Odegard PS, Maki IV, Tomkowiak J. Interprofessional collaboration: three best practice models of interprofessional educa-
tion. Med Educ Online. 2011;16(10). http://www.tandfonline.com/doi/full/10.3402/meo.v16i0.6035. Accessed February 2, 2017.
2. Interprofessional education and its impact on the education of audiologists and speech-language pathologists. American Speech-Language-Hearing
Association Web site. http://www.asha.org/Articles/Interprofessional-Education-and-its-Impact-on-the-Education-of-Audiologists-and-Speech-
Language-Pathologists/. Published June 2008. Accessed May 2, 2017.
3. Interprofessional Education Collaborative. Core competencies for interprofessional collaborative practice: Report of an expert panel. American
Association of Colleges of Nursing Web site. http://www.aacn.nche.edu/education-resources/ipecreport.pdf. Published 2011. Accessed May 2, 2017.
4. Interprofessional Education and Collaborative Practice Resources. American Physical Therapy Association Web site. http://www.apta.org/Educators/
Curriculum/Interprofessional/. Published March 31, 2017. Accessed May 2, 2017.
5. Goldberg LR. The importance of interprofessional education for students in communication sciences and disorders. Commun Disord Q. 2014;35:3-4.
6. Rapport MJ, Furze J, Martin K, et al. Essential competencies in entry-level pediatric physical therapy education. Pediatr Phys Ther. 2014;26(1):7-18.
7. American Occupational Therapy Association. Importance of interprofessional education in occupational therapy curricula. Am J Occup Ther.
2015;69:1-14.
8. Pecukonis E, Doyle O, Bliss DL. Reducing barriers to interprofessional training: promoting interprofessional cultural competence. J Interprof Care.
2008;22:417-428.
9. Poulton BC, West MA. The determinants of effectiveness in primary health care teams. J Interprof Care. 1999;13:7-18.
Section 1
Interprofessional Approaches to
Pediatric Practice
Catherine Rush Thompson, PT, PhD, MS and Pamela Hart, PhD, CCC-SLP

with other professionals when making decisions that impact

OVERVIEW all those providing care and those receiving care. These
skills are referred to as interprofessional competencies.
This first section sets the tone for the entire book by
What are these interprofessional competencies and how
describing and delineating interprofessional competencies
were they determined? Recognizing that effective teamwork
for pediatric therapists and those unique to each profes-
is essential to family-centered care, experts in public health
sion, referred to as complementary competencies. Given the
and health care began determining interprofessional compe-
importance of understanding other professionals’ roles and
tencies by exploring competencies expected of all health pro-
responsibilities, this section further provides an outline of
fessionals, or common competencies.1 These interprofessional
the various professionals typically encountered in pediatric
competencies were compared with those that were deemed
care. It then describes the importance of role clarification,
unique or defining of each profession, or complementary
collaborative leadership, and team functioning as key inter-
competencies. Finally, the common competencies that were
professional competencies needed for effective teamwork,
considered essential for effective collaboration were iden-
emphasizing the importance of appreciating the comple-
tified as interprofessional competencies, as illustrated in
mentary competencies that define the roles and respon-
Figure 1-1. Interprofessional competencies are those com-
sibilities of other team members. Finally, it describes the
mon competencies that should be developed to ensure effec-
various team approaches used in pediatric care, including
tive teamwork when providing care.
intradisciplinary, multidisciplinary, interdisciplinary, trans-
disciplinary, and collaborative team approaches. In Core Competencies for Interprofessional Collaborative
Practice, an expert panel from the Interprofessional
Education Collaborative representing public health and
health care fields distinguished the following 4 domains for
INTERPROFESSIONAL COMPETENCIES what they determined to be core interprofessional compe-
tencies.1 Each of these 4 domains is based upon a guiding
Interprofessional skills go beyond those practiced exclu- principle that describes the domain and provides the basis
sively by those providing individualized care for children. of the competencies within that domain. The 4 domains are
This skill set recognizes key competencies for collaboration as follows:

Thompson CR. Pediatric Therapy:

An Interprofessional Framework for Practice (pp 1-13).
-1- © 2018 SLACK Incorporated.
2 Section 1

Figure 1-1. This diagram illustrates the complementary skills (unique to occupational therapy, physical therapy, and speech language pathology)
and overlapping interprofessional skills that are shared across professions. These interprofessional competencies lay the foundation for effective
teamwork.

1. Competency Domain 1: Values/Ethics for Interprofessional professionals in a responsive and responsible manner that
Practice1: The key principle for this domain is supports a team approach to the maintenance of health
expressed in the following statement: Work with and the treatment of disease. This domain includes 8
individuals of other professions to maintain a climate competencies that address key communication skills,
of mutual respect and shared values. In addition to as outlined in Table 1-3.
abiding by professional values and standards, each 4. Competency Domain 4: Teams and Teamwork1: The
professional is expected to share common values and final domain emphasizes the importance of team-
ethics for interprofessional practice. This principle is work and is guided by the following statement: Apply
supported by 10 interprofessional competencies, as relationship-building values and the principles of team
outlined in Table 1-1. dynamics to perform effectively in different team roles to
2. Competency Domain 2: Roles/Responsibilities1: The sec- plan and deliver patient-/population-centered care that
ond domain is based upon another key principle: Use is safe, timely, efficient, effective, and equitable. This
the knowledge of one’s own role and those of other profes- domain incorporates 11 competencies that address
sions to appropriately assess and address the health care key teamwork skills essential for interprofessional col-
needs of the patients and populations served. This guid- laboration, as outlined in Table 1-4.
ing principle lays the foundation for its corresponding All of the competencies incorporate principles and values
8 competencies, as outlined in Table 1-2. embraced by pediatric therapists. All therapists agree that
3. Competency Domain 3: Interprofessional care should be patient centered and community oriented.
Communication1: This competency focuses on the From the pediatric therapist’s perspective, care should be
importance of communication with others, as out- child centered, family centered, and context specific to ensure
lined in the following statement: Communicate success in all environments. In addition, care should focus
with patients, families, communities, and other health on relationship building, so therapists must build trust with
 Interprofessional Approaches to Pediatric Practice 3

TABLE 1-1
VALUES AND ETHICS COMPETENCIES
VE1 Place the interests of patients and populations at the center of interprofessional health care delivery.
VE2 Respect the dignity and privacy of patients while maintaining confidentiality in the delivery of team-
based care.
VE3 Embrace the cultural diversity and individual differences that characterize patients, populations, and
health care team.
VE4 Respect the unique cultures, values, roles/responsibilities, and expertise of other health professions.
VE5 Work in cooperation with those who receive care, those who provide care, and others who contribute
to or support the delivery of prevention and health services.
VE6 Develop a trusting relationship with patients, families, and other team members.
VE7 Demonstrate high standards of ethical conduct and quality of care in one s contributions to team-
based care.
VE8 Manage ethical dilemmas specific to interprofessional patient-/population-centered care situations.
VE9 Act with honesty and integrity in relationships with patients, families, and other team members.
VE10 Maintain competence in one s own profession appropriate to scope of practice.
Adapted from Interprofessional Education Collaborative. Core Competencies for Interprofessional Collaborative Practice. American
Association of Colleges of Nursing Web site. https://nexusipe-resource-exchange.s3-us-west-2.amazonaws.com/IPEC_
CoreCompetencies_2011.pdf. Published 2016. Accessed May 2, 2017.

TABLE 1-2
ROLES AND RESPONSIBILITIES COMPETENCIES
RR1 Communicate one s roles and responsibilities clearly to patients, families, and other professionals.
RR2 Recognize one s limitations in skills, knowledge, and abilities.
RR3 Engage diverse health care professionals who complement one s own professional expertise, as well as
associated resources, to develop strategies to meet specific patient care needs.
RR4 Explain the roles and responsibilities of other care providers and how the team works together to
provide care.
RR5 Use the full scope of knowledge, skills, and abilities of available health professionals and health care
workers to provide care that is safe, timely, efficient, effective, and equitable.
RR6 Communicate with team members to clarify each member s responsibility in executing components of
a treatment plan or public health intervention.
RR7 Forge interdependent relationships with other professions to improve care and advance learning.
RR8 Engage in continuous professional and interprofessional development to enhance team performance.
Adapted from Interprofessional Education Collaborative. Core Competencies for Interprofessional Collaborative Practice. American
Association of Colleges of Nursing Web site. https://nexusipe-resource-exchange.s3-us-west-2.amazonaws.com/IPEC_
CoreCompetencies_2011.pdf. Published 2016. Accessed May 2, 2017.
4 Section 1

TABLE 1-3
INTERPROFESSIONAL COMMUNICATION COMPETENCIES
CC1 Choose effective communication tools and techniques, including information systems and
communication technologies, to facilitate discussions and interactions that enhance team function.
CC2 Organize and communicate information with patients, families, and health care team members in a
form that is understandable, avoiding discipline-specific terminology when possible.
CC3 Express one s knowledge and opinions to team members involved in patient care with confidence,
clarity, and respect, working to ensure common understanding of information and treatment and care
decisions.
CC4 Listen actively and encourage ideas and opinions of other team members.
CC5 Give timely, sensitive, instructive feedback to others about their performance on the team, responding
respectfully as a team member to feedback from others.
CC6 Use respectful language appropriate for a given difficult situation, crucial conversation, or
interprofessional conflict.
CC7 Recognize how one s own uniqueness, including experience level, expertise, culture, power, and
hierarchy within the health care team, contributes to effective communication, conflict resolution, and
positive interprofessional working relationships.
CC8 Consistently c ommunicate the importance of teamwork in patient-centered and community-focused care.
Adapted from Interprofessional Education Collaborative. Core Competencies for Interprofessional Collaborative Practice. American
Association of Colleges of Nursing Web site. https://nexusipe-resource-exchange.s3-us-west-2.amazonaws.com/IPEC_
CoreCompetencies_2011.pdf. Published 2016. Accessed May 2, 2017.

TABLE 1-4
TEAMS AND TEAMWORK INTERPROFESSIONAL COMPETENCIES
TT1 Describe the process of team development and the roles and practices of effective teams.
TT2 Develop consensus on the ethical principles to guide all aspects of patient care and teamwork.
TT3 Engage other health professionals̶appropriate to the specific care situation̶in shared patient-
centered problem solving.
TT4 Integrate the knowledge and experience of other professions̶appropriate to the specific care
situation̶to inform care decisions while respecting patient and community values and priorities/
preferences for care.
TT5 Apply leadership practices that support collaborative practice and team effectiveness.
TT6 Engage self and others to constructively manage disagreements about values, roles, goals, and actions
that arise among health care professionals and with patients and families.
TT7 Share accountability with other professions, patients, and communities for outcomes relevant to
prevention and health care.
TT8 Reflect on individual and team performance for individual, as well as team, performance improvement.
TT9 Use process improvement strategies to increase the effectiveness of interprofessional teamwork and
team-based care.
TT10 Use available evidence to inform effective teamwork and team-based practices.
TT11 Perform effectively on teams and in different team roles in a variety of settings.
Adapted from Interprofessional Education Collaborative. Core Competencies for Interprofessional Collaborative Practice. American
Association of Colleges of Nursing Web site. https://nexusipe-resource-exchange.s3-us-west-2.amazonaws.com/IPEC_
CoreCompetencies_2011.pdf. Published 2016. Accessed May 2, 2017.
 Interprofessional Approaches to Pediatric Practice 5

Role Clarification

Child’s/Family’s Collaborative
Needs in the Leadership
Setting

Interprofessional
Communication

Conflict Team Functioning

Resolution

Interprofessional
Goals for
Learning &
Healthy
Development

Figure 1-2. This diagram illustrates key interprofessional competencies essential to pediatric care.

children, their families, and others to ensure support and of professional roles and responsibilities. Most importantly,
carryover between all settings, including the home, school, team members must work toward common outcomes that
and community. Considerable evidence suggests that trust address the goals of the child and family.
in clinicians is based upon (1) the clinician’s technical com- One framework, the National Interprofessional
petence, (2) respect for the family’s/client’s views, (3) sharing Competency (NIC) framework, describes competencies
of relevant information, and (4) the client’s own confidence required for effective interprofessional care.4 The NIC frame-
in managing his or her illness.2,3 Because parents play an work suggests key competencies foundational to collab-
essential role in their children’s care, empowering children orative decision making that honors the knowledge, skills,
and their families to help manage health- and education- values, and experience of all involved. Figure 1-2 illustrates
related issues through advocacy and self-advocacy are key these key competencies deemed essential to interprofessional
elements of building trust in pediatrics. care.
As critical thinkers, pediatric therapists appreciate that This interprofessional framework offers key concepts that
interprofessional collaboration is process oriented. Shared can be adapted to pediatric settings4:
decision making is an ongoing effort that requires con- 1. Role Clarification: All team members must understand
tinual assessment and critical input from all involved in care. their own role, as well as the roles of others on their
Collaborative efforts ensure that children are engaged in team. Respecting each other’s roles and knowledge
developmentally appropriate learning activities and that ther- contributes to establishing and meeting appropriate
apists use educational strategies and behavioral assessments goals.
that guide their interactions with all involved. These efforts 2. Child-/Family-/School-Centered Care: Team members
should be well integrated across the learning continuum and must value the input and engagement of each person,
sensitive to differences in settings (eg, home, community, including the child, family members, community
clinic, school). members, and others involved in the child’s life.
To facilitate effective interprofessional collaboration,
professionals need a common language and understanding
6 Section 1

3. Interprofessional Communication: All team members Physical therapists have advanced degrees (doctoral train-
must clearly communicate with each other in a col- ing), pass a national licensure examination, and are licensed
laborative, responsive, respectful, and responsible by each state to work with individuals across their lifespan
manner. Professionals must be thoughtful in sharing to manage pain and improve or restore mobility. Physical
and collecting information, allocating sufficient time therapists are uniquely “movement experts” who examine
to listen carefully to family members and other profes- all body systems and functions (musculoskeletal, neu-
sionals working on the team. romuscular, cardiopulmonary, integumentary, and other
4. Conflict Resolution: Team members must be able to body systems) to determine how they contribute to postural
deal with interprofessional conflict and problem solv- control and mobility. Physical therapists evaluate growth,
ing that best meets the needs of children and their psychosocial and physical development, motor skills related
families. Factors that can reduce team conflict include to daily activities, and each individual’s roles in life, as well
(1) delineating a clear purpose or agenda for meetings, as environmental, personal, and other factors that could
(2) determining a manageable team size and team impact any individual’s ability to move and to participate
composition, (3) having organizational support, (4) fully and optimally in life, whether it be at home, school,
scheduling convenient team meetings, (5) developing work, or during leisure activities. Physical therapists provide
clear goals and objectives, (6) reflecting on what is professional care in a wide range of settings, including, but
effective for reaching team goals and objectives, and not limited to, hospitals, private practices, outpatient clin-
(7) being open to needed changes.5 ics, home health agencies, schools, sports and fitness facili-
5. Team Functioning: All professional team members ties, work settings, and nursing homes. According to the
must appreciate the principles of team dynamics and Academy of Pediatric Physical Therapy:
group processes for effective interprofessional col- Pediatric physical therapists use their expertise in
laboration. Table 1-5 illustrates some characteristics movement and apply clinical reasoning through
of effective team dynamics and group processes, rein- the process of examination, evaluation, diagnosis,
forcing the interprofessional competencies needed in and intervention. As primary health care provid-
pediatric care. ers, physical therapists also promote health and
6. Collaborative Leadership: Decision making is not wellness as they implement a wide variety of sup-
top-down or bottom-up; collaboration between team ports for children from infancy through adoles-
members should allow every voice to be equally heard cence in collaboration with their families and other
and understood. All team members should work medical, educational, developmental, and rehabili-
together to formulate a plan to meet the needs of each tation specialists. Pediatric physical therapy pro-
child and family, to implement the plan, and to evalu- motes independence, increases participation, facili-
ate the effectiveness of the plan. As needed, the plan tates motor development and function, improves
can be modified to enhance the child’s outcomes. The strength and endurance, enhances learning oppor-
partnership between everyone on the team must be tunities, and eases challenges with daily caregiving.6
participatory, collaborative, and coordinated to ensure In many practice settings, physical therapist assistants
ongoing decision making that addresses the complex assist in care. According to the APTA, physical therapist
issues facing each child. assistants “provide physical therapy services under the direc-
tion and supervision of a licensed physical therapist. Physical
therapist assistants help people of all ages who have medical
SCOPES OF PRACTICE FOR THERAPISTS problems, or other health-related conditions that limit their
ability to move and perform functional activities in their
AND OTHERS WORKING IN daily lives.”7 In the school setting, physical therapists pro-
vide consultation and support to staff to improve students’
PEDIATRIC SETTINGS educational performance related to functional gross motor
development, whereas physical therapist assistants help with
All team members must understand and respect the therapeutic activities designed to support educational goals.
knowledge of others. The scope of practice of therapists In the hospital setting, physical therapist assistants provide
and paraprofessionals working in pediatric settings is sup- health education and physical therapy interventions to
ported by their respective professional organizations, such improve their patients’ health and wellness.
as the American Physical Therapy Association (APTA), Another therapist commonly seen in pediatric settings
the American Occupational Therapy Association (AOTA), is the occupational therapist. The AOTA describes the scope
and the American Speech-Language-Hearing Association of practice of occupational therapy as “the therapeutic
(ASHA). The following are definitions of each professional use of occupations, including everyday life activities, with
with definitions of their practice expertise:
 Interprofessional Approaches to Pediatric Practice 7

TABLE 1-5
DYNAMICS AND GROUP PROCESSES FOR PEDIATRIC INTERPROFESSIONAL TEAMS
CATEGORY CHARACTERISTICS
Child/family focused • Focuses care on the child and family
• Recognizes need for holistic care for child and family
• Values child s and family s needs and goals
• Provides timely interventions to match needs
Culture • Supports an interprofessional atmosphere, valuing contributions of
all team members
• Nurtures consensus, providing a safe environment for sharing ideas
• Works toward common goals
• Uses a proactive/health promotion approach
• Facilitates an environment for team meetings (eg, adequate time for meeting
preparation, discussion at meeting, and follow-up; convenient location for team
meeting; good representation of those impacted by decision making; capacity of
team members is clear; organization provides support; meetings are documented
with decisions made)
Communication • Holds regular case conferences to share information
• Communicates both formally and informally
• Shares information to ensure a holistic perspective
• Possesses strong listening and clear communication skills
• Avoids use of jargon
Learning • Recognizes the need to learn with others
• Supports a culture that enhances interprofessional learning and development of
cultural competencies
• Explores creative solutions to unique pediatric challenges
Roles and • Understands own and others roles and responsibilities
responsibilities • Brings a high level of professional competency, knowledge, and skills
• Provides a positive role model for the profession represented
• Recognizes the need to practice professional autonomy, if needed
• Incorporates resources for team building
Team members • Recognizes the optimal size and structure for team needs
• Appreciates contributions of all team members
• Explores and accepts overlapping role(s)
• Recognizes professional synergy through mutual support
• Tolerates different opinions and perceptions
• Recognizes the need for lateral leadership
• Recognizes the level of learning of each team member
Adapted from Nancarrow S, Booth A, Ariss S, Smith T, Enderby P, Roots R. Ten principles of good interdisciplinary team work. Hum Resour
Health. 2013;11:19.
8 Section 1

individuals, groups, populations, or organizations to sup- result of developmental disabilities, hearing impairment,
port participation, performance, and function in roles and traumatic brain injury, cleft palate, or learning disabilities
situations in home, school, workplace, community, and to name a few.
other settings.”8 As stated by Trombly, “Occupational thera- Speech-language pathology assistants are defined by ASHA
pists are experts in occupational functioning.”9 This role is as “support personnel who, following academic coursework,
evident across practice settings, similar to those of physi- fieldwork, and on-the-job training, perform tasks pre-
cal therapists, but also including mental health facilities. scribed, directed, and supervised by ASHA-certified speech-
School-based occupational therapists use their knowledge of language pathologists.”14
occupation areas (ie, activities of daily living, instrumental Physical therapists, occupational therapists, and speech-
activities of daily living, rest and sleep, education, work, language pathologists are commonly seen working in both
play, leisure and social participation) to assess and select hospital and school settings. Similarly, nurses provide a
interventions considering the limitations of the child and the valuable health care link in educational settings. Nursing
activity demands within the school environment for optimal involves “the protection, promotion, and optimization of
academic and nonacademic performance. In the school set- health and abilities, prevention of illness and injury, facilita-
ting, occupational therapists provide services to students, tion of healing, alleviation of suffering through the diagno-
supporting their educational and functional needs related sis and treatment of human response, and advocacy in the
to sensory responsiveness, motor performance, percep- care of individuals, families, groups, communities, and pop-
tual processing, and psychosocial and cognitive abilities.10 ulations,” according to the American Medical Association.15
Occupational therapists practicing in schools have strongly Although most nurses work in general medical and surgical
recognized the importance of providing support and col- hospitals, many work in elementary and secondary schools
laborating with educational professionals, school staff, and to provide health services on site.
the families of the children they serve.11 A broad range of specialists work predominantly in
Similar to physical therapist assistants, certified occupa- medical vs educational settings. The following are some
tional therapy assistants and occupational therapy aides are professionals who are most commonly encountered in these
supervised by occupational therapists and perform activi- settings. For those not listed, therapists should consult pro-
ties that enhance occupational services in educational and fessional websites and job descriptions for team members,
medical practice settings.12 In the school setting, certified as well as appreciate the experience that each individual
occupational therapy assistants provide quality skilled occu- contributes to interprofessional collaboration.
pational therapy services to children and consult with teach-
ers and school staff under the direction of an occupational
therapist. Certified occupational therapy assistants can con-
tribute to all facets of school-based services with adherence
MEDICAL TEAMS
to federal and state laws and AOTA documents.12
Medical care facilities are typically where specialists deal
Speech-language pathologists play an important role in with acute and emergent medical conditions and recovery
pediatric settings to help establish effective communication from illness. The emphasis in pediatric medical settings is
and safe feeding and swallowing strategies for young clients. on promoting a child’s recovery to function and stabilizing
According to ASHA: a child’s physiological and structural integrity. In addition to
The speech-language pathologist is the professional physical therapists, occupational therapists, speech-language
who engages in clinical services, prevention, advocacy, pathologists, and nurses, children and their families engage
education, administration, and research in the areas with a wide range of health care professionals to manage
of communication and swallowing across the lifespan acute and chronic conditions. Interprofessional teams in
from infancy through geriatrics. Speech-language hospitals may include therapists, nurses, physicians, physi-
pathologists address typical and atypical impairments cian assistants, audiologists, recreation therapists, nutrition
and disorders related to communication and swal- specialists, social workers, family members, and others. The
lowing in the areas of speech sound production, reso- following are team members commonly encountered in
nance, voice, fluency, language (comprehension and medical settings.
expression), cognition, and feeding and swallowing.13 Physicians are medical experts who serve as the heads of
In the school setting, speech-language pathologists pro- medical teams in most health care settings. According to
vide assessment and intervention services for students with the American Medical Association (AMA), physician-led
disorders in speech, language, cognition, swallowing/dys- team-based health care is defined as “the consistent use by a
phagia, fluency, and/or voice. These disorders may be the physician of the leadership knowledge, skills, and expertise
necessary to identify, engage, and elicit from each team
 Interprofessional Approaches to Pediatric Practice 9

member the unique set of training, experience, and quali-

fications needed to help patients achieve their goals, and to
TEAM MEMBERS IN THE
supervise the application of these skills.”15 In pediatrics, the
specialists commonly seen by children include neonatolo-
SCHOOL SETTING
gists, pediatricians, neurologists, cardiologists, urologists, Team members in the school setting are committed to
orthopedists, physiatrists, and other experts who deal with the education of all children and offer their expertise to help
childhood pathologies. children achieve academic goals. Pediatric therapists will
Physician assistants practice medicine on teams with most likely encounter teachers (including special education
physicians, surgeons, and other health care workers. They teachers), counselors, school psychologists, resource special-
are licensed to diagnose and treat illness and disease and ists, and adaptive physical educators.
to prescribe medication for patients. They commonly work Teachers serve multiple roles in educational settings. Most
in physician’s offices, hospitals, and clinics in collaboration importantly, school teachers educate our nation’s children
with a licensed physician.16 and adolescents about the world, teaching foundational
Audiologists provide assessment and intervention services knowledge and skills and engaging them in learning activi-
to individuals with disorders affecting auditory and/or bal- ties to develop their critical thinking skills. They develop
ance function. Specific roles include prevention of hearing lesson plans designed to teach their subjects, such as math-
loss, assessment of hearing loss, fitting individuals with ematics, reading, science, and social studies, and help stu-
hearing aids and other assistive devices, as well as services to dents develop interpersonal communication skills. Teachers
help individuals with cochlear implants achieve their highest serve as role models for their students and encourage student
level of function.17 development through exploration and discovery. In the
Recreational therapists design therapeutic recreation, school setting, teachers work diligently with support staff to
involving planning, directing, and coordinating recreation- help students meet educational goals and achieve academic
based treatment programs for people with disabilities, success. Teachers evaluate the abilities and weaknesses of
injuries, or illnesses.18 In the hospital setting, therapeutic their students. They play a key role in identifying students
recreation uses a range of leisure activities as interventions who struggle with learning and making referrals to special
to engage children in problem solving. Activities can include education services.
games, sports, parties, and music. Special education teachers are educators who are specially
A nutrition specialist holds a license to practice dietetics trained to work with students who have a wide range of
and nutrition services, whereas a licensed dietitian facilitates learning, mental, emotional, and physical disabilities. As
nutrition therapy. They are responsible for encouraging team leaders in the school setting, special education teachers
healthy food choices, assessing and coordinating nutritional provide direct and indirect instructional support and behav-
menus, and working with families to encourage appropri- ioral strategies to students’ learning. Oftentimes, they must
ate diets.19 Nutrition specialists are typically employed at modify the general education curriculum for students with
hospitals; however, they also provide consultation to schools disabilities based upon a variety of instructional techniques
and communities. and technologies and consult closely with pediatric thera-
Social workers are highly trained and experienced profes- pists to optimize each student’s outcomes.22
sionals. According to the National Association of Social Counselors empower children and their families to accom-
Workers, only those who have earned social work degrees at plish mental health and wellness. The American Counseling
the bachelor’s, master’s, or doctoral level and have completed Association notes that professional counselors are “graduate
a minimum number of hours in supervised fieldwork are level (either master’s or doctoral degree) mental health ser-
professional social workers.20,21 Those working in pediatrics vice providers, trained to work with individuals, families,
will most likely encounter social workers in schools, hospi- and groups in treating mental, behavioral, and emotional
tals, mental health clinics, and numerous public and private problems and disorders.”23
agencies that serve individuals and families in need.20,21 The school psychologist assists in the identification of
Interprofessional team members and administrative staff the intellectual, social, and emotional needs of students.
in a hospital setting must collaborate efficiently and effec- Their entry-level education for school psychology includes
tively to ensure that families transition into and out of medi- a specialist-level or master’s degree in psychology and state
cal care as easily as possible. This transition includes the pro- licensure.24 Given their specialized training, psychologists
vision of community resources and referrals to help children provide consultation and support to families and staff
and their families optimally return to their daily lives. regarding behavior and conditions related to learning. They
also plan behavioral programs to meet the special needs of
10 Section 1

children and often serve as facilitators during interprofes- receive care through various state-funded, hospital-based,
sional team meetings to determine individualized programs or private clinical facilities. To the greatest extent possible,
for students. infants and toddlers should be served in their natural envi-
Resource specialists are licensed or certified teachers who ronment, such as a home or day care setting.26 Laws govern-
provide instructional planning and support and direct ing pediatric therapy will be discussed in greater detail in
services to students whose needs have been identified in chapters related to therapy provided in educational settings.
an Individualized Education Program (IEP).23 Resource Early intervention programs are typically offered to
specialists are typically assigned to general education class- families in their home setting. These services are provided
rooms for the majority of their school day. in hopes of empowering and educating families about how
Adapted physical educators are trained to provide specially to help children with special needs learn about themselves
designed physical education programs for students who and their environment and develop skills for interaction
require special instruction in physical education. Physical and engagement with other children, adults, and the com-
education teachers need to meet all the qualifications for munity. As children grow older, they may receive additional
a teaching certification or licensure, and adapted physical therapeutic assistance to develop needed skills to func-
educators may have additional certification through the tion more independently in the adult world with others.
Adapted Physical Education National Standards (APENS).25 Oftentimes, pediatric therapists help families with locating
The APENS states that adapted physical education is “physi- additional supports for their adolescents as they enter adult-
cal education which has been adapted or modified, so that hood, aiding in the transition to independent living, group
it is as appropriate for the person with a disability as it is homes or returning home.
for a person without a disability.”25 These educators work Another role of pediatric therapists is to encourage
with team members to ensure active engagement in physical community involvement of children and their families.
activities in school settings and may serve on the team that Therapists benefit their families by connecting them with
helps to develop a child’s IEP. local recreational settings, sports activities, community cen-
ters, sites supporting Special Olympics, adult day programs
for older youth, and other local options that encourage par-
SERVICE DELIVERY ticipation and socialization.

The provision of care in both medical and educational

settings is based upon laws, regulations, and the funding REFERRAL PROCESS
available for each setting. In general, pediatric care that
is provided in a medical setting is covered by insurance, Referrals to pediatric therapies are dependent upon mul-
public funding (for those qualified), and/or personal funds. tiple factors, including the practice environment, funding
Medical facilities range from outpatient clinics with limited sources, and laws governing care provided in a chosen set-
health care options to hospital-based management that may ting. For example, very premature newborns are commonly
feature more extensive care, ranging from neonatal and identified as needing pediatric therapy services while they
pediatric intensive care to inpatient and outpatient reha- are in the neonatal intensive care unit. Generally, these
bilitation services. Depending upon the complexity, sever- infants are monitored for their growth and development
ity, and chronicity of illness, children may spend extended over time to determine whether they are physiologically
lengths of time in the hospital, receiving both medical and stable or at risk for developmental delays or health problems.
educational services, if needed. Payment for services in Their subsequent development and growth dictate the need
hospital-based care is generally covered by private insurance, for care. Early monitoring helps to identify children with
Medicaid, and personal funds. significant risk factors or apparent problems requiring the
Educational settings are mandated by law to provide expertise of pediatric therapists. Subsequent chapters will
a free, appropriate public education (FAPE) in the least discuss how children are referred to various types of care
restrictive environment (LRE) with consideration given to based upon their age and the practice setting. Case studies in
any therapeutic, special education, or assistive technology this book will include discussion of how decisions are made
necessary to help the child or adolescent meet goals listed to determine optimal care for children with special needs.
in the student’s IEP.26 School districts are responsible for
providing educational and therapeutic services to children
with special needs 3 to 21 years.26 Infants and toddlers may
 Interprofessional Approaches to Pediatric Practice 11

• Transdisciplinary Team Approach27,28: Team members

VALUE OF INTERPROFESSIONAL work together to examine and evaluate the child, as well
TEAMWORK as design and plan an intervention that can be carried
out by all team members. In this approach, the profes-
Interprofessional teamwork refers to work involving dif- sional roles cross boundaries of typical disciplines and
ferent professionals who share a team identity and work the delivery of care is consistent across care providers.
closely together in an integrated and interdependent man- This approach is more commonly seen in infant devel-
ner to solve problems and deliver services. Although it can opment programs, some acute care settings (especially
be challenging to work with other team members due to neonatal intensive care units [NICUs]), and educational
the additional time and effort needed to meet, interprofes- settings.
sional teamwork has been shown to improve outcomes. This • Collaborative Team Approach29: Team members work
additional time and effort enables shared decision making, closely together in a combination of transdisciplinary
allows deeper discussion and debate of important issues, and integrated therapy approaches. Therapists might
improves joint planning, and enhances communication delegate the majority of intervention to a teacher or aide
across the team. Additionally, team members tend to adopt to be carried out when the child is in a functional set-
shared values about delivering care in an interprofessional ting, such as a classroom.
manner. Regardless of the setting, interprofessional collaboration
is essential for desired outcomes. Each team member can
serve as a consultant, educator, team player, and advocate
TEAM APPROACHES USED IN for each child and family. By bringing together the unique
strengths of each profession and developing interprofessional
VARIOUS PEDIATRIC SETTINGS competencies that strengthen collaboration, therapists can
optimize care for those they serve.
Depending upon the environment, pediatric therapists
may use varying team approaches that best suit the type
of care needed. These include intradisciplinary, multidisci-
plinary, interdisciplinary, and collaborative team approaches.
SUMMARY
The range of terms used to describe these team approaches
can prove confusing for those new to a practice setting. Interprofessional competencies are built upon key princi-
Although similar, each approach has certain distinctions ples that are embraced by pediatric therapists. Four domains
that are described here. developed by the Interprofessional Education Collaborative
(built upon guiding principles embraced by pediatric thera-
• Intradisciplinary Team Approach27: Team members indi-
pists) include (1) values and ethics, (2) roles and responsibili-
vidually conduct an examination of the child, plan an
ties, (3) communication, and (4) teamwork. A framework of
appropriate intervention, and carry out the plan with
interprofessional pediatric care, adapted from the National
the help of therapy assistants or aides within the same
Interprofessional Competency Framework, focuses on 6 key
discipline, as needed. This approach is more commonly competencies, including (1) role clarification, (2) child-/fam-
seen in private practice or outpatient settings. ily-/school-centered care, (3) interprofessional communica-
• Multidisciplinary Team Approach27: Team members tion, (4) conflict resolution, (5) team functioning, and (6)
individually conduct an examination of the child, then collaborative leadership. These competencies are essential
write a report that is shared with other team members. for interprofessional collaboration in all settings, including
Meetings are held to discuss each discipline’s exami- home, community, medical and educational settings.
nation and plan for treatment. Plans for intervention The delivery of interprofessional care depends upon the
and the execution of each intervention are discipline practice setting and the referral process but always involves
specific. This approach is more commonly seen in acute collaborative teamwork for optimal outcomes. The best
care and outpatient facilities. team approach can be determined through interprofessional
• Interdisciplinary Team Approach27: Although each mem- communication based upon a clear understanding of legal
ber of the team individually examines the child, profes- factors dictating the priorities and delivery of care.
sionals share information across disciplines to develop Section 2 provides an overview of both shared and
a plan of care. Team members may incorporate some discipline-specific frameworks used by pediatric therapists;
aspects of other disciplines’ care plans into their own Section 3 describes cultural competence and strategies to
interventions. This approach is more commonly seen in improve intercultural communication; Section 4 outlines
school settings, some acute care hospitals, and rehabili- typical growth and development; and Section 5 discuss-
tation facilities. es how pediatric therapists manage pediatric care. The
12 Section 1

remainder of this book provides examples of teamwork in a surgically repaired heart defect, an enlarged tongue, general-
wide range of practice settings, including the NICU; early ized low muscle tone, bilateral hearing loss, risk for immune
intervention; early childhood special education; elementary, deficiency, low-set ears, a tendency to mouth breathe, a risk
middle, and high schools; and medical settings. Each set- for polycythemia, slight seborrheic dermatitis on her scalp,
ting provides unique opportunities for pediatric therapists single line on both palms, thickening of the skin of the
to optimize care through interprofessional collaboration in palms and soles, and problems with her vision. Discuss what
program development, transitions across practice settings, you think your roles would be with Sandy and her family,
and advocacy for needed services. including what would be similar vs distinctive, based upon
your professional training.

INTERPROFESSIONAL ACTIVITY Case 1-2: A 5-year-old boy with athetoid

cerebral palsy
Compare and contrast the roles of pediatric therapists
and other professionals by looking at the descriptions of Jason is a 5-year-old boy with a medical diagnosis of
their practice, their educational backgrounds, and their athetoid cerebral palsy.31,32 Jason’s family just moved to
professional websites. your town after living in a rural, underserved community
with no access to therapy services. Jason just turned 5 years
Begin by reviewing descriptions in this chapter, then
old and is eager to enter kindergarten. As a team, you are
review professional websites, as needed, to elaborate on
observing Jason for the first time. Discuss what you think
understanding.
your roles would be with Jason and his family, including
Discuss the following questions:
what would be similar vs distinctive, based upon your pro-
1. What do pediatric therapists have in common? List 5 fessional training.
characteristics.
2. How are pediatric therapists unique and distinctive
from other professionals in educational and medical
settings? List at least 2 distinctions for your profession.
REFERENCES
3. What factors may lead to conflict between profession- 1. Interprofessional Education Collaborative. Core Competencies for
als and families? Interprofessional Collaborative Practice. American Association of
Colleges of Nursing Web site. https://nexusipe-resource-exchange.
4. How can conflicts between professionals and families
s3-us-west-2.amazonaws.com/IPEC_CoreCompetencies_2011.pdf.
be minimized? Published 2016. Accessed May 2, 2017.
5. What does the term collaborative leadership mean to 2. Dibben M, Lena M. Achieving compliance in chronic illness man-
you, and how do you determine who should lead dis- agement: illustrations of trust relationships between physicians and
nutrition clinic patients. Health Risk Soc. 2003;5(3)(suppl):241-259.
cussions with family members?
3. Krupat E, Bell R, Kravitz R, et al. When physicians and patients think
6. As a team, describe similar vs distinctive roles working alike: patient-centred beliefs and their impact on satisfaction and
trust. J Fam Pract. 2001;50(12)(suppl):1057-1062.
with the following 2 cases:
4. Canadian Interprofessional Health Collaborative. A National
Interprofessional Competency Framework. Vancouver, Canada: College
of Health Disciplines University of British Columbia; 2010.
5. Xyrichis A, Lowton K. What fosters or prevents interprofessional
teamworking in primary and community care? A literature review. Int
J Nurs Stud. 2008;45(1):140-153.
6. Academy of Pediatric Physical Therapy. The ABCs of Pediatric
Physical Therapy. Academy of Pediatric Physical Therapy Web site.
Case 1-1: A 6-month-old girl with Down https://pediatricapta.org/includes/fact-sheets/pdfs/09%20ABCs%20
of%20Ped%20PT.pdf. Published 2009. Accessed May 2, 2017.
syndrome 7. American Physical Therapy Association. The Physical Therapist Scope
of Practice. American Physical Therapy Association Web site. http://
Sandy is a 6-month-old girl with a medical diagnosis of www.apta.org/ScopeOfPractice/. Published November 20, 2015.
Down syndrome.30 Sandy is being seen in an outpatient Accessed January 24, 2017.
follow-up clinic following a recent heart surgery for her 8. American Occupational Therapy Association. Scope of Practice.
atrioventricular septal defect. Sandy was identified as high Pacific University Web site. https://www.pacificu.edu/sites/default/
files/documents/10-Scopeofpractice.pdf. Published 2005. Accessed
risk at birth and has delayed development (motor, cogni- January 24, 2017.
tion, communication, and social-emotional). Her physical 9. Trombly C. Anticipating the future: Assessment of occupational func-
features include short stature, brachycephaly (a dispropor- tion. Am J Occup Ther. 1993;47:253-257.
tionate shortness of head), upslanting palpebral fissures, 10. Case-Smith J. Occupational Therapy for Children and Adolescents. 4th
atlantoaxial instability, a bent little finger on both hands, a ed. St. Louis, MO: Mosby; 2001.
 Interprofessional Approaches to Pediatric Practice 13

11. Clark GF, Chandler BE, eds. Best Practices for Occupational Therapy in 22. Special education terms and definitions. Understanding Special
Schools. Bethesda, MD: AOTA Press; 2013. Education Web site. http://www.understandingspecialeducation.com/
12. Jost M, Rohn JL. Best practices in the role of occupational therapy special-education-terms.html. Published 2016. Accessed November
assistants in schools. In: Clark G, Chandler B, eds. Best Practice 18, 2016.
for Occupational Therapy in Schools. Bethesda, MD: AOTA Press; 23. American Counseling Association. About us. American Counseling
2013:35-40. Association Web site. https://www.counseling.org/about-us/about-aca.
13. American Speech-Language-Hearing Association. Scope of practice in Published 2017. Accessed January 24, 2017.
audiology. ASHA. 1996;38(suppl 16):12-15. 24. American Psychology Association. School psychologists. National
14. American Speech-Language-Hearing Association. Frequently asked Association of School Psychologists. https://www.nasponline.org/
questions: Speech-Language Pathology Assistants (SLPAs). American about-school-psychology/who-are-school-psychologists. Published
Speech-Language-Hearing Association Web site. http://www.asha. 2017. Accessed May 10, 2017.
org/associates/SLPA-FAQs/. Published 2017. Accessed December 28, 2017. 25. Adapted Physical Education National Standard. What is adaptive
15. American Medical Association. Physician-led team-based care. physical education? Adapted Physical Education National Standard
American Medical Association Web site. https://www.ama-assn. Web site. http://www.apens.org/whatisape.html. Accessed May 10,
org/delivering-care/physician-led-team-based-care. Accessed May 10, 2017.
2017. 26. Center for Parent Information and Resources. IDEA—the Individuals
16. American Academy of Physician Assistants. What is a PA? American with Disabilities Education Act. Center for Parent Information and
Academy of Physician Assistants Web site. https://www.aapa.org/ Resources Web site. http://www.parentcenterhub.org/repository/idea/.
What-is-a-PA/. Accessed May 10, 2017. Published September 4, 2010. Accessed May 10, 2017.
17. American Speech-Language-Hearing Association. Scope of practice 27. Stember M. Advancing the social sciences through the interdisciplin-
in audiology. American Speech-Language-Hearing Association Web ary enterprise. The Social Science Journal. 1991;28(1):1-14.
site. http://www.asha.org/policy/SP2004-00192/. Published 2004. 28. Kilgo JL. Transdisciplinary teaming from a higher education perspec-
Accessed January 24, 2017. tive. In: Kilgo JL, ed. Transdisciplinary teaming in early intervention/
18. Hawkins BL, Cory LA, McGuire FA, Allen LR. Considerations for early childhood special education: Navigating together with families
therapeutic recreation practitioners, school systems, and policy mak- and children. Olney, MD: Association for Childhood Education
ers. J Disabil Policy Stud. 2010;23(3):131-139. International; 2006:77-80.
19. The Academy Quality Management Committee and Scope of Practice 29. Bridges DR, Davidson RA, Odegard PS, Maki IV, Tomkowiak J.
Subcommittee of the Quality Management Committee. Academy of Interprofessional collaboration: three best practice models of inter-
Nutrition and Dietetics: Scope of Practice for the Registered Dietitian. professional education. Med Educ Online. 2011;16(10). http://www.
Idaho Academy of Nutrition & Dietetics Web site. http://www. tandfonline.com/doi/full/10.3402/meo.v16i0.6035. Published April 8,
eatrightidaho.org/app/uploads/archive/uploads/Scope-of-Practice-for- 2011. Accessed February 2, 2017.
the-Registered-Dietitian.pdf. Published 2013. Accessed May 10, 2017. 30. Asim A, Kumar A, Muthuswamy S, Jain A, Agarwal S. Down syn-
20. Learn.org. What does a pediatric nutritionist do? Learn.org Web drome: an insight of the disease. J Biomed Sci. 2015;22(1):41.
site. http://learn.org/articles/What_Does_a_Pediatric_Dietician_ 31. Centers for Disease Control. Facts about cerebral palsy. Centers
Do.html. Published 2017. Accessed April 24, 2017. for Disease Control and Prevention Web site. https://www.cdc.gov/
21. National Association of Social Workers. Social work profession. ncbddd/cp/facts.html. Published February 3, 2017. Accessed May
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brainandspinalcord.org/athetoid-dyskinetic/. Published 2017.
Accessed May 2, 2017.
Section 2
Interprofessional Frameworks of
Pediatric Practice
Catherine Rush Thompson, PT, PhD, MS; Pamela Hart, PhD, CCC-SLP; and
Ketti Johnson Coffelt, OTD, MS, OTR/L

that impact a person’s ability to engage fully in life, referred

OVERVIEW to as participation. For example, it looks at the person’s
health condition (medical diagnoses), body systems and body
Educational training of professionals working in pediatric functions impacted by that health condition, the individual’s
practice settings share common theoretical frameworks and activities (skills or abilities), the environment (both physical
approaches for managing children with special needs. This and psychosocial) impacting the individual’s ability to per-
section discusses the frameworks of practice commonly used form these skills, personal factors (such as motivation, age,
by pediatric therapists and those that explain differences in gender, and lifestyle factors), and, finally, participation (the
perspectives when assessing and developing interventions to extent the individual is able to participate in all aspects of
help children and families in need. life) (Figure 2-1).1
Pediatric therapists are experts at assessing a child’s abili-
ties and skills, as well as identifying likely body structures
INTERNATIONAL CLASSIFICATION and body functions that can impact these activities or skills.
Further, therapists recognize how the environment (both
OF FUNCTIONING, DISABILITY AND physical and psychological) plays a key role in how children
HEALTH demonstrate certain skills and behaviors, such as how a
child might behave on a public playground compared with
The World Health Organization describes the how she plays in her own backyard. A vital feature of this
International Classification of Functioning, Disability and framework is the concept of participation. A primary goal
Health (ICF) Model as “a classification of health and of all pediatric therapists is to ensure that each child has
health-related domains, as the functioning and disability of opportunities to fully participate in life. This goal includes
an individual occurs in a context.”1 As a broad conceptual the role of advocacy for children and their families to pro-
framework, the ICF Model is used internationally for mea- mote legislation and social attitudes empowering families
suring health and disability at both individual and popula- and enabling children with special needs to access resources
tion levels. The ICF Model categorizes the multiple factors that enable full participation that most families enjoy.

Thompson CR. Pediatric Therapy:

An Interprofessional Framework for Practice (pp 15-27).
- 15 - © 2018 SLACK Incorporated.
16 Section 2

Figure 2-1. International Classification of Functioning, Disability and Health.

• Participants make decisions jointly.

FAMILY-CENTERED CARE • Family-centered care acknowledges the family as the
According to the Maternal and Child Health Bureau constant in a child’s life.
Division of Services for Children with Special Health Needs: • Family-centered care builds on family strengths.
Family-centered care (FCC) assures the health • Family-centered care supports the child in learning
and well-being of children and their families about and participating in his care and decision making.
through a respectful family-professional partner- • Families and professionals work together in the best
ship. It honors the strengths, cultures, traditions, interest of the child and the family. As the child grows,
and expertise that everyone brings to this rela- she assumes a partnership role and begins to advocate
tionship. Family-centered care is the standard of for herself.
practice which results in high-quality services.2 • Everyone respects the skills and expertise brought to the
Regardless of practice setting, pediatric therapists rec- cross-disciplinary relationships.
ognize the importance of involving families and empower- • There is an openness and willingness to negotiate.
ing caretakers engaged in each child’s care. This common • Family-centered care honors cultural diversity and fam-
philosophy of family-centered care is the cornerstone of ily traditions.
early intervention provided for young children designed • Family-centered care recognizes the importance of
to empower parents to be their child’s first teacher. The community-based services.
principles of family-centered care, developed by researchers
and organizations supporting families, recognize the impor- • Family-centered care promotes an individual and devel-
tance of a partnership between families and the pediatric opmental approach.
professionals and experts serving them.2-5 This essential • Family-centered care encourages family-to-family and
partnership can be strengthened by adhering to the follow- peer support.
ing principles2-5: • Family-centered care supports youth as they transition
• Trust is acknowledged as fundamental a principle. to adulthood.
• Communication and information sharing are open As members of an interprofessional team, pediatric thera-
and objective. pists who embrace these principles can help to empower
 Interprofessional Frameworks of Pediatric Practice 17

families as they gain the skills and knowledge to support • Providing reinforcement of desired behaviors for maxi-
their children with special needs. Pediatric therapists rec- mum function. For example, the team should give the
ognize their role and responsibilities for educating parents, child structured choice making throughout the therapy
caretakers, and other family members about each child’s spe- session, determining the child’s preferred therapeu-
cial needs, just as they respect the unique perspectives that tic activities and using them for reinforcing desired
families provide in assessing and addressing their concerns. behaviors.
Family education includes: Pediatric therapists must value the family-centered care
• Providing a rationale for assessment. For example, does framework as they work with children with special needs
the child demonstrate delayed developmental skills? from birth to adulthood. Table 2-1 lists crucial behaviors for
The interprofessional team must explain why these professionals offering family-centered care.
issues are important for the child’s development for
independent function. If appropriate, the team should
explain who made the referral and why. Consider a
child who has difficulty copying information from the
SYSTEMS APPROACH
board, suggesting a wide range of sensory, motor, cogni- There are many dynamic systems theories that view
tive, and/or language problems. These problems could changes in development from different perspectives, ranging
be further assessed using a team approach. from mathematical to movement theories.6,7 These theories
• Providing a rationale for treatment strategies and tech- recognize multiple factors impacting child development.
niques. For example, the interprofessional team needs The impact of these biomechanical, developmental, and
to educate the child who is paralyzed and his caretakers environmental factors lead to the dynamic changes that
regarding the reason it is important to maintain normal children experience as they grow and develop.6,7 Pediatric
joint mobility and monitor skin integrity secondary to therapists are trained in assessing these factors and how
sensory loss. they change across the lifespan. For example, the changes
• Providing resources for support (eg, emotional, psycho- in a child during the first year of life include growth in size;
logical, equipment needs). For example, the interprofes- changes in the development and integration of motor, lan-
sional team should contact support groups (eg, United guage, psychosocial, and cognitive skills; alternations in the
Cerebral Palsy, Muscular Dystrophy Association, Spina home environment; and the emergence of a unique personal-
Bifida Association, and others), local vendors of durable ity the child displays over time.
equipment, parent support groups, and local funding Given that infants and children grow so dramatically
sources that can provide needed assistance. during the first decade of life, pediatric therapists regularly
assess these dynamic changes in body systems and their
• Consulting for comprehensive care. For example, the
functions over time. For children with special needs, each
interprofessional team should encourage parents to
pediatric therapist attempts to positively impact the child’s
actively participate in team conferences to discuss goals,
motor, cognitive, language, and psychosocial skills with
progress, and modifications in treatment. Also, the
the ultimate goal of enabling the child to participate in
team needs to maintain contacts with other profession- age-appropriate life skills and roles. As noted earlier, pedi-
als (eg, therapists providing services in hospital clinics, atric therapists share their knowledge and skills with family
school-based therapists, home health therapists, ortho- members to infuse consistency of therapeutic care during
tists, vendors of equipment, orthopedists, neurologists, the dynamic processes of growth and development.
primary care physicians) to educate them regarding the
child’s progress or other issues of concern.
• Recommending therapeutic activities for all environ-
ments (eg, home, school, work, recreation). For exam-
DEVELOPMENTAL FRAMEWORK
ple, professionals should learn about local activities that The developmental framework recognizes that each child
might encourage motor skill development (eg, tell the must be embraced as a whole person who is growing and
child and families about local swimming programs, developing emotionally, socially, physically, intellectually,
summer camps, and opportunities for hippotherapy). and culturally.8,9 Jean Piaget is best known for his contri-
• Attempting to combine individual goals together for the butions to developmental psychology through his observa-
most meaningful function in a given context. For exam- tions of child development and recognition of the various
ple, the team could have the child work on sitting bal- stages that typical children experience from birth through
ance while using augmentative communication. These adolescence9:
skills are functional because the child can communicate
while working on gross motor and fine motor skills.
18 Section 2

TABLE 2-1
SIGNIFICANT BEHAVIORS FOR FAMILY-CENTERED CARE RELATED TO INTERPROFESSIONAL CARE
ROLE CLARIFICATION
• Clarify your role for all team members, especially family members and caretakers
• Share relevant information related to your expertise

COLLABORATIVE LEADERSHIP
• Recognize the expertise of team members (professional and other areas of strengths)
• Assist in identifying children s strengths
• Assist in identifying children s needs
• Consider the psychosocial needs of all team members
• Mentor and guide each other s collaborative decision making
CHILD S AND FAMILY S NEEDS
• Use cultural competency skills
• Recognize the family s strengths
• Distinguish the child s strengths
• Believe and trust parents
• Respect coping styles
• Collaborate with parents in decision making
• Encourage parent advocacy
• Respect and support the family
• Provide individualized services
• Provide accessible services
• Value families routines and demanding lifestyles
INTERPROFESSIONAL COMMUNICATION
• Listen to all team members, especially family members
• Communicate clearly and concisely
• Communicate without using jargon
• Be prepared to provide examples or illustrations, as needed
• Be open to new ideas and perspectives
CONFLICT RESOLUTION
• Watch carefully for signs of conflict during verbal and nonverbal communication
• Recognize problems and negotiate to resolve conflicts as soon as possible
TEAM FUNCTIONING
• Encourage participation of all members
• Encourage use of community supports
• Respect the roles, responsibilities, and expertise of team members and stakeholders
INTERPROFESSIONAL GOALS
• Discuss the rationale for each goal
• Prioritize goals that meet the child s and family s needs
• Provide information to the family about how the team plans to reach goals
 Interprofessional Frameworks of Pediatric Practice 19

• The sensorimotor stage, from birth to 2 years, when the

infant senses and explores the world through play and
TASK-ORIENTED APPROACH
manipulation.
From the neuroscientific perspective, the task-oriented
• The preoperational stage, from 2 to about 7 years, when approach assumes that individuals are task or goal oriented,
the child begins to develop an imagination and logic based upon how the brain functions and activates body sys-
through play and exploration. tems.10,11 This approach suggests that multiple factors work
• The concrete operational stage, from 7 to 11 years, when together in the growing child to produce movement and
the child develops very concrete thinking and is capable control posture that is organized by the brain to accomplish
of appreciating the thoughts of others. a desired task. This foundational theory of motor control
• The formal operational stage, which begins in adoles- views the body as mechanical systems that work together
cence and spans into adulthood, when the youth is more to move.11 Pediatric therapists view this theory as founda-
capable of using critical thinking, logic, abstract think- tional to understanding all the body systems and how they
ing, and deductive reasoning. work cooperatively in managing internal and environmental
Positive relationships and experiences with nurturing influences for performing daily tasks. One example of the
caregivers in the early years are critical for mental and task-oriented approach would be having the child complete
physical health. Good nutrition and safe, healthy, and an obstacle course that requires cognitive and language
stimulating environments have a positive impact on a child’s skills as well as motor planning. According to this theory,
development. the child should focus on completion of the obstacle course
rather than focusing on the individual stimuli presented in
Frequently, pediatric therapists rely on developmental
the challenging course.
assessments providing insight into the child’s overall devel-
opmental progression. Recognizing the typical develop-
mental milestones facilitates surveillance of healthy child
development and offers an opportunity to identify possible PLAY-BASED APPROACH
problems early in life.
Challenges for pediatric therapists include: Play is activity engaged in for enjoyment and recreation.
• Determining what to use as a foundation for interven- A child’s play involves active engagement and is intrinsically
tion: typical movement patterns as compared with motivated.12 Although play may not have obvious extrinsic
atypical movements for the child with limited physical goals, it can promote a sense of wonder, exploration, inves-
abilities. tigation, and interest in a rich range of materials, resources,
and opportunities. “Play provides the most natural and
• Determining whether the child’s communication and meaningful process by which children can construct knowl-
social skills are outside the range of typical language edge and understanding, practice skills, immerse themselves
development for her age. naturally in a broad range of literacy and numeracy, and
• Risking the development of independence at the cost of engage in productive, intrinsically motivating learning
the child’s developing deformities from atypical move- environments.”12
ment patterns (eg, chronic asymmetrical use of one side The play-based approach recognizes the value of play as a
of body could lead to scoliosis). vehicle for learning and development13-16:
• Determining the combination of therapeutic approach- Research shows that children are playing-learn-
es that will be optimal for the child’s needs across the ing individuals. In an open and tolerant atmo-
lifespan. The range of therapeutic approaches are dis- sphere, where children are free to make their own
cussed later in this section. choices, both play and learning dimensions will
• Recognizing that perspectives on therapeutic manage- be present. Children do not separate play and
ment change as the child grows and develops new skills learning unless they are influenced by adults.16
and interests. Furthermore, this approach employs a child’s motivation
Interprofessional approaches within the developmental to engage in experiences based upon their developmental
framework help pediatric therapists collaborate with families skills, individual strengths, and unique interests. In other
and other disciplines to prioritize needs collectively identi- words, children learn by being active.17
fied and most valued by families and health care providers.
20 Section 2

Effective strategies for supporting learning through this

approach encourage therapists to:
THERAPEUTIC APPROACHES
1. Balance play, noting how often the child leads or initi-
Habilitation refers to learning movements for the first
ates play;
time.20 Pediatric therapists become experts at recognizing
2. Provide needed supports to facilitate play (including the habilitation potential of children by examining current
toys, environmental structure, and other children, as evidence regarding realistic expectations for children with
appropriate); specific diagnoses. In some cases where children have con-
3. Engage in conversations during play to engage the genital malformations or significant functional limitation,
child individually or in group problem solving and team members can work collaboratively to offer children
discussion, if possible; and opportunities for participation in a wide range of activities
4. Support the inclusion of all children in play for psy- through creative adaptations, as needed. The habilitation
chosocial benefits. approach is commonly used to help children achieve motor
Ideally, a play-based program relies on the child’s inter- milestones through play-based activities that provide mul-
ests, routines, and creative ideas. Play can take place in a tiple opportunities for practicing challenging skills. The
wide range of environments and incorporates all types of habilitation approach typically applies the progression of
play, from sensory play (eg, painting with whipping cream) developmental milestones to guide therapeutic activities.
to constructive play (eg, building a model airplane). The Modification occurs when the child is unable to achieve
interprofessional team can brainstorm with the child to a task without adaptation. Modification allows the child to
identify materials, games, interests, and locations for play more fully participate in structured activities, resulting in
that address his unique abilities and learning styles. For self-determined or self-controlled strategies to solve motor
optimal play, the team should incorporate the child’s own problems.20 For example, a child needing to perform a
ideas and interests into planned experiences and routines. task, such as eating lunch, might require modifications of
Play offers each child an opportunity to develop motor, the eating task and specialized equipment that makes the
cognitive, and psychosocial skills that lead to psychological task easier to perform. Developing appropriate modifica-
and emotional control while exploring the environment. For tions relies on interprofessional collaboration to determine
this reason, play is the basis for the majority of pediatric optimal therapeutic positioning, adaptive devices, and social
therapy. The basic stages of play behavior through which interaction supports for the child to successfully accomplish
children normally progress are listed in Table 2-2.18,19 the task. As the child grows and develops new skills, equip-
Pediatric therapists are frequently asked for age-appropri- ment and learning materials are often modified to enable the
ate toys for children based upon their ages. In all instances, child to gain more independent function.
toys should be geared to the child’s chronological age rather Preventive care is anticipated for every child. One hall-
than cognitive age because motor function might limit mark of preventive care is that it should be integrated into
opportunities to engage with toys offering sufficient intel- daily activities in the natural setting. Preventive care can
lectual changes for certain children. Some electronic toys include health recommendations (eg, immunizations, diet,
can be adapted to enable children with motor dysfunction, sleep, nutrition), environmental changes (eg, arrangement
such as those with cerebral palsy, to activate toys with a of the physical environment, proximity of objects, space for
master switch or other control device. Table 2-3 lists age- safe movement), and behavioral changes (eg, safe transfers,
appropriate toys for play-based learning. training in use of devices, staff education, parent education).
Finally, the social aspects of play are a fundamental Everyone must be certain that each child engages in activi-
consideration for structuring play activities with other ties designed to reduce risks and to eliminate secondary
children.17-19 Table 2-4 lists the typical ages at which the complications resulting from the primary impairments, such
various types of play emerge, ranging from solitary play as weakness, limited range of motion, and sensory deficits.
typically seen in infants to gang or team play typically seen For example, children who have difficulties moving are
as children engage in school activities. prone to developing contractures (limited joint movement),
Although play is used as the primary means of engag- skin breakdown, and deformities. The interprofessional
ing children in therapeutic activities, the pediatric therapist team must integrate preventive care while developing thera-
must also consider the optimal therapeutic approach that peutic activities to promote age-appropriate skills.
best meets the child’s medical and educational needs, rang- Remediation occurs when a child engages in activi-
ing from helping her learn early in life to aiding in recovery ties designed to correct, remedy, or improve skills.20 For
from a serious accident during adolescence. example, a 1-year-old child with increased muscle tone
 Interprofessional Frameworks of Pediatric Practice 21

TABLE 2-2
STAGES OF PLAY
INFANCY (BIRTH TO 24 MONTHS)
The infant:
• Experiments with bodily sensations and movements
• Establishes important social attachments (largely by being held and matching voices to smiles and other
facial expressions)
• Engages in self-discovery: playing with hands and feet
• Is attracted to toys with sharp, contrasting colors; changes in sound; or changes in texture
• Observes others in play
• Seeks objects that they can grasp, push, or pull to master motor abilities and develop coordination
• Demonstrates communicative intent through play
TODDLERHOOD (2 TO 3 YEARS)
The toddler:
• Develops independence and a sense of self through practice play and repetition
• Enjoys conversations/books
• Enjoys social games (eg, peek-a-boo and pat-a-cake)
• Learns to take turns
• Enjoys hiding games: find the object/person
• Pretend play: care for dolls, make dinner, shop
• Demonstrates a variety of communicative functions through play
EARLY CHILDHOOD (3 TO 5 YEARS)
The preschooler:
• Enjoys make-believe play and imitating others
• Love to engage in gross motor play (running, jumping, climbing, and throwing) as well as
rough-and-tumble activities (especially males)
• Enjoys social interaction with peers, taking turns
• Engages in constructive play: playing with blocks and build structures; water painting; working with
modeling clay, water, sand, and rice, with reports of increased mathematical scores
MIDDLE CHILDHOOD (6 TO 10 YEARS)
School-aged children:
• Enjoy competition and explicit rules that stress fair play and satisfy social and intellectual challenges; this
type of play builds self-esteem, which is so important to middle childhood
• Enjoy playing games with their family
º Games with strategy: chess and checkers
º Games with skills: card games encourage math skills
ADOLESCENCE (11 TO 18 YEARS)
Adolescents/young adults:
• Enjoy competitive games and sports
• Enjoy computer and video games/indoors play (they foster spatial cognition skills, with reports of increased
mathematical scores)
• Improve gross motor skills
Adapted from Pathways. Stages of play. Pathways Web site. https://pathways.org/blog/kids-learn-play-6-stages-play-development/.
Accessed May 10, 2017.
22 Section 2

TABLE 2-3
AGE-APPROPRIATE TOYS FOR PLAY-BASED LEARNING
AGE RANGE APPROPRIATE TOYS AND GAMES
1 month to The infant is visually focused, developing sensorimotor skills, and engaged in exploring the
6 months environment. Popular toys encourage reaching, grasping, holding and mouthing (eg, rattles,
objects of a solid primary color hung in easy view, cradle gym or mobile, bells on an elastic
band, fuzzy toys, and musical toys).
6 to 12 months The infant is more socially aware of others and enjoys interactive games like peek-a-boo and
pat-a-cake. Toy play expands to different textures and environments, including playing with
floating toys, putting water in containers and pouring it out, and picking up and throwing
down objects.
1 year to With increasing mobility, the toddler enjoys chasing and hiding games, watching and
1.5 years following (imitating actions), and engaging in a wide range of motor skills (eg, walking,
climbing, bending over, sitting down, turning pages in books, manipulating handling
objects, scribbling, smearing, pounding, and arranging objects in order). The toddler also
enjoys dancing and clapping to music.
1.5 to 2 years As fine motor skills refine and postural control improves, the toddler enjoys creatively playing
with finger paints, clay, sand, water, soap, wooden toys (cars and animals), blocks, crayons,
and paper. With increased balance, the toddler enjoys rocking on a large toy and holding a
book while turning pages.
2 to 3 years The young child enjoys participating in parallel play and hearing stories over and over again.
Activities that engage gross motor movements (eg, toys to push and pull, climbing, kicking
and throwing) and fine motor skills (eg, taking simple things apart, building block towers,
stringing beads, putting together simple puzzles, placing objects in a row, and repeatedly
emptying and filling containers) amuse the child.
3 to 4 years Social skills become more evident as the young child begins taking turns. Cognitive and
motor skills are explored as the child recognize the results of efforts (eg, putting together
more complex puzzles, performing imaginative block play, playing dress-up, using
dress-up clothes, dropping objects through small openings, using instruments to create
rhythm, rhyming, drawing, and painting). Movements involving increased coordination (eg,
hopping and jumping) and motor planning (eg, maneuvering through obstacle courses)
further develop.
4 to 5 years By 4 years, the child enjoys cooperative play and begins sharing toys. Play is more
constructive and creative (eg, cutting and pasting objects, building structures, and playing
with a wider range of toys that refine gross and fine motor skills). The child s cognitive and
emotional development is more evident (eg, she wants her creations saved and recognizes
numbers and letters).
6 to 7 years From 6 years on, the child engages in a wider range of toys and appreciates cooperative
and self-directed activities (eg, playing card and board games, creating art with a range of
materials, reading books, and enjoying mechanical toys). Children over the age of 6 typically
love sports, including those that involve manipulation (eg, sports involving gloves, balls, and
bats) and increasing coordination (eg, riding a bicycle). As children continue to develop and
become exposed to the wide range of possible activities, they show greater preferences for
those activities that match their abilities and interests.
Adapted from BabyCenter. Age-appropriate toys. BabyCenter Web site. https://www.babycenter.com/0_age-appropriate-toys_5.bc.
Accessed May 10, 2017 and St. Louis Children s Hospital. Age-appropriate toys and activities. St. Louis Children s Hospital Web site. http://
www.stlouischildrens.org/sites/default/files/wellness_development/files/SLC10659_AgeAppropriateToysBrochureR3.pdf. Accessed May
10, 2017.
 Interprofessional Frameworks of Pediatric Practice 23

TABLE 2-4
SIX TYPES OF PLAY
THE FOLLOWING 6 TYPES OF PLAY DEVELOP FROM BIRTH TO 6 YEARS:
1. Unoccupied play (begins at birth)
This is the most basic type of play. The infant gains awareness of her surroundings and basically
observes the environment.
2. Independent or solitary play (emerges around 2 to 3 years)
The infant plays alone with her body parts, smiles at other babies, attends to other babies cries, and
begins to explore other children.
3. Onlooker play (emerges at 2 years)
Two children engage in solitary play while in close proximity, exchanging toys, imitating each other, and
following and chasing each other. This type of play is common among children developing their
communication skills.
4. Parallel play (emerges around 3 years)
Children demonstrate conscious cooperation and work together to accomplish a task (eg, building with
blocks). As a child matures, the duration and complexity of the task increases. The group size also grows,
so rules and laws are developed by the group to regulate behaviors.
5. Associative play (emerges around 3 years)
As children develop friendships, they become more involved in group play, but their play is not well
organized. In addition to their motor skills, they are engaged in more socialization, problem solving,
cooperation, and use of language.
6. Cooperative play (school age)
As children mature, they spontaneously form groups with membership. To show solidarity, these groups
may develop nicknames for group identification.
Adapted from Gudritz L. 6 types of play important to your child s development. Healthline Web site. http://www.healthline.com/health/
parenting/types-of-play. Published June 20, 2016. Accessed May 10, 2017 and Wellhousen K, Crowther I. Creating Effective Learning
Environments. Clifton Park, NY: Cengage Learning; 2004:4-7.

might “bunny hop” (using a primitive reflex, symmetrical Maintenance activities help a child retain acquired func-
tonic neck reflex, for movement) rather than creep recipro- tional skills. Repetition of functional skills enables a child to
cally. Encouraging the child to creep reciprocally (using maintain the ability to perform these skills over time.20 For
verbal and/or manual assistance) helps the child to develop example, once a child learns to walk, he should be expected
new strategies for movement on the floor. Remediation to walk on a regular basis. The focus of therapy would then
also involves training in the use of assistive technology and shift from walking to walking with increased speed and
devices that enable a child to communicate and engage in endurance. Similarly, once a child learns new words or fine
purposeful classroom and functional activities. motor skills, the interprofessional team should encourage
Compensation occurs when intervention programs are frequent use of these new skills to maintain their use in the
designed to promote other aspects of performance or sub- child’s daily routines.
stitute a different form of action.20 For example, children Although all of the approaches discussed thus far are
with athetosis need to stabilize their posture and extremities commonly shared by pediatric therapists, some perspectives
for more control of their movements. A child with athetosis are unique to each profession. The management of a child’s
could learn to dress herself using the wall for postural sup- care is enriched by the distinctive models and approaches
port. Similarly, this child could learn to use elbow support that physical therapists, occupational therapists, and speech-
(eg, using a table or stabilizing her elbow against her trunk) language pathologists bring to their interprofessional teams.
for fine motor control. Both of these are compensatory strat-
egies to assist with motor control.
24 Section 2

and child. The desired outcome of physical therapy is to

PHYSICAL THERAPY: assist each child in becoming as healthy as possible (includ-
THE PATIENT/CLIENT MANAGEMENT ing physically, mentally, and psychosocially) and to enable
each child to fully participate at home and school, in recre-
MODEL ational opportunities, and in the community in a meaning-
ful manner.
The Patient/Client Management Model is uniquely used
by physical therapists to deliver care across all practice set-
tings and patients/clients.21 With a strong emphasis on OCCUPATIONAL THERAPY:
growth and development, the pediatric physical therapist
performs an extensive review of systems that includes the OCCUPATION-BASED APPROACH
musculoskeletal, neuromuscular, cardiopulmonary, integu-
mentary, and other body systems and relates findings to the The Occupational Therapy Framework: Domain and
child’s growth, development, and motor control. Process (Third Edition)24 provides a guided outline of occu-
Examination addresses (a) aerobic capacity and endur- pational therapy services for individuals such as a child
ance; (b) anthropometric characteristics; (c) assistive technol- and her family with the overall aim to develop the child’s
ogy; (d) balance; (e) circulation (arterial, venous, lymphatic); occupation participation in roles, habits, and routines.
(f) community, social, and civic life; (g) cranial and periph- Occupational therapy practice is dependent upon the spe-
eral nerve integrity; (h) education life; (i) environmental fac- cific condition and age of the child and can occur within a
tors; (j) gait; (k) integumentary integrity; (l) joint integrity variety of contexts, such as the home, a medical setting (eg,
and mobility; (m) mental functions; (n) mobility (including hospital, rehabilitative facility, outpatient facility), and edu-
locomotion); (o) motor function; (p) muscle performance cational classrooms (preschool through high school grades).
(including strength, power, endurance, and length); (q) neu- Occupational therapists analyze a child’s occupation
romotor development and sensory processing; (r) pain; (s) performance in the following areas: activities of daily living
posture; (t) range of motion; (u) reflex integrity; (v) self-care (self-feeding, functional mobility, bathroom skills, manag-
and domestic life; (w) sensory integrity; (x) skeletal integrity; ing classroom materials); instrumental activities of daily
(y) ventilation and respiration; and (z) work life.21 Although living (bicycling, riding buses, walking); rest and sleep,
all areas may not be examined in all children, these areas education (academic, nonacademic, extracurricular, and
serve as the foundation for the management of pediatric vocational); and play and social participation (peers and
conditions in both educational and medical settings. others). The emphasis for occupational therapists practicing
According to the Guide to Physical Therapist Practice,21 in the school learning environment is to identify factors that
intervention is the “purposeful interaction of the physical affect students’ “learning and participation in the context of
therapist with an individual—and, when appropriate, with educational activities, routines, and environments.”25
other people involved in that individual’s care—to produce Occupational therapists observe and assess each child’s
changes in the condition that are consistent with the diag- performance skills of (a) cognition, (b) emotional regula-
nosis and prognosis.” Evaluation considers examination tion, (c) visual perceptual, (d) fine motor, (e) gross motor, (f)
results and interactions between the child and others. The sensory processing, (g) sensory integration, (h) motor plan-
physical therapy diagnosis is determined, specifying activity ning, and (i) social-emotional abilities—all of which may
limitations. In pediatrics, impaired neuromotor development be limiting their occupational performance in the hallway,
is a common physical therapy diagnosis because many chil- lunchroom, classroom, playground, and other relevant set-
dren have difficulty with achieving typical developmental tings. Based on an analysis of the occupation, performance
milestones. The prognosis for physical therapy is based upon skills, and activity demands of the task, along with the occu-
the child’s potential for the development of neuromotor pational profile of the child, occupational therapists create
skills and learning adaptive skills to function optimally. The intervention strategies to develop necessary skills and make
plan of care is developed based upon an integration of the adaptations or modifications to support the child’s overall
evaluation and the goals of family and other stakeholders. learning performance.
The outcomes of physical therapy are based upon objective Drawing from theories and known evidence, occupa-
SMART goals that are monitored closely throughout the use tional therapists use clinical reasoning during the occu-
of evidence-based interventions.22,23 The SMART acronym pational therapy process of evaluation and intervention
is used to ensure that goals are specific, measurable, achiev- planning in the development of individualized educational
able, realistic, and time sensitive.22,23 programming. Occupational therapists continually review
The evaluation process continues throughout interven- programming and monitor the child’s progress, assessing
tions to accommodate changing environments (eg, school the effectiveness of their interventions and making changes
needs vs home needs) and the changing needs of the family as necessary. Occupational therapists realize that learning
 Interprofessional Frameworks of Pediatric Practice 25

opportunities exist for children all day long, thus they place research evidence for or against the chosen intervention
value in the collaborative consultation process with teachers toward a goal of maximizing client progress in the most
and paraprofessional educators to exchange information, efficient manner as possible.27
educate each other, and train skills and strategies so that All pediatric therapists are expected to engage in pro-
children can continually practice skills and embed routines fessional development and critical analyses of research to
enhancing school performance.25 ensure that they offer the most contemporary and evidence-
based care to meet the needs of children and their families.
Interprofessional collaboration relies on this professional
SPEECH-LANGUAGE PATHOLOGY: development for optimal outcomes in all practice settings.

THE SPEECH-LANGUAGE PATHOLOGY

PRACTICE FRAMEWORK WORKING IN EDUCATIONAL VERSUS
The practice of speech-language pathology is conceptu-
MEDICAL SETTINGS
alized by cardinal documents from the American Speech- Pediatric therapists are employed in various settings,
Language-Hearing Association (ASHA) outlined in the including hospitals, outpatient clinics, school systems, and
Scope of Practice, Preferred Practice Patterns, Position community-based settings. The provision of care at each
Statements, Knowledge Guidelines, and Knowledge and setting is contingent upon laws, regulations, and funding
Skill Statements.26 These documents describe the depth and sources.
breadth of practice in speech-language pathology. General Subsequent sections will provide an overview of inter-
areas of practice for speech-language pathologists include professional pediatric therapy in a range of settings. Section
assessment and intervention across (a) speech sound pro- 6 covers medical care in the neonatal intensive care unit,
duction, (b) resonance, (c) voice, (d) fluency, (e) expressive Section 7 discusses family-centered care in early interven-
language, (f) receptive language, (g) social pragmatic skills, tion, Section 8 describes child-centered early childhood
(h) cognition, (i) feeding and swallowing, and (j) commu- special education, Section 9 relates therapeutic supports to
nication modalities, including augmentative and alternative educational settings (elementary, middle, and high schools),
communication strategies. These broad, diverse areas of and Section 10 discusses urgent care in hospital settings.
clinical knowledge and skill require an understanding of Table 2-5 illustrates the range of settings that warrant dif-
how the disorder affects the individual’s ability to func- ferent approaches of care based upon legal and financial
tion in daily life. As such, the general practice framework considerations.
in speech-language pathology is based on the previously
described World Health Organization’s ICF Model.1 Within
this framework, impairments may range from minor to major.
Relative to speech-language pathology, a client who has SUMMARY
cerebral palsy may experience severe impairments in health
conditions, specifically body functions, to the extent that This section provided an overview of the similarities
she is unable to use verbal speech for communication. This between physical therapy, occupational therapy, and speech-
same client, however, may have positive contextual factors, language pathology in terms of the approaches used in the
including family support and adequate financial resources, management of children receiving care in various practice
thus enabling access to services in a supportive environment settings. It also outlined the different perspectives each type
that enables her to experience greater success. Application of therapy offers to children and their families based upon
of this framework to speech-language pathology encourages the context of care and the unique needs of each child.
consideration of the whole person and the ways the disability Section 3 will discuss the cultural competency needed to
impacts various aspects of the person’s life. address diverse needs and values of families and settings,
Also central to the practice of speech-language pathology and Section 4 will provide details regarding typical growth
is the use of research evidence, stakeholder perspectives, and and development. Section 5 will describe how pediatric
clinical judgment as a comprehensive method of evidence- therapists use their expertise to manage the needs of chil-
based practice.27 It is no longer adequate to approach clini- dren and their families. Sections 6 through 10 will focus
cal service provision as a speech-language pathology with a on specific pediatric practice settings, providing additional
philosophy of “I use this approach because it works.” It is details regarding the legal and ethical considerations for
now the expectation that speech-language pathologists use each setting, the populations typically served, the expected
their clinical judgment while including stakeholder per- roles of health care professionals, and the focus of the inter-
spectives in the development of the treatment plan. This is professional team.
completed with full consideration and analysis of the related
26 Section 2

TABLE 2-5
SETTINGS FOR PEDIATRIC THERAPY
MEDICAL HOME-BASED EDUCATIONAL OTHER
• NICU (neonatal intensive • Early intervention • Preschool • Sports centers
care unit) (in home or early • Elementary • Community centers
• PICU (pediatric intensive intervention programs) school • Parks
care unit) • Homebound • Secondary • Playgrounds
• Inpatient • Group home school • Adult day programs
• Outpatient • College • Shopping centers
• Rehabilitation • Entertainment centers
• Outpatient clinics
• Urgent care

INTERPROFESSIONAL ACTIVITY
1. Read the following case studies and consider the
needs of each child across childhood and the roles Case 2-1: A 4-year-old girl with
and responsibilities of physical therapy, occupational myelomeningocele28
therapy, and speech-language pathology in managing
children with special needs. Cindy was diagnosed with myelomeningocele T4-T6 and
2. Answer the following questions for each case: obstructive hydrocephalus secondary to Chiari II malforma-
tion shortly after birth. Cindy’s mother reports that she has
a. What would you expect in terms of this child’s
always been healthy and never took any medications that
growth and development compared with others of
would impact her pregnancy. After Cindy’s birth, the fam-
the same age?
ily noted a mass growing in her upper spine, so they sought
b. What types of assessments would be commonly medical care, including a ventriculo-peritoneal shunt for
used across all pediatric therapies? (See Appendix her hydrocephalus. At age 2, Cindy had a seizure that was
B for a list of tests and measures used by pediatric treated in the emergency department. At age 3, Cindy began
therapists.) demonstrating temper tantrums and had difficulty with
c. What might be distinctive assessments for physi- her right eye and right jaw. Cindy is now 4 years old, and
cal therapy, occupational therapy, and speech- the interprofessional team needs to address her needs. The
language pathology for each child and his or her family just moved to your rural area, and you need to assess
family? Cindy’s abilities in the local clinic.
d. How would you conduct an interprofessional
assessment? Case 2-2: A 10-year-old boy with
e. What frameworks would you apply to your plan of autism spectrum disorder
care for the child and family?
f. How would you adjust your presentation of results Zachary is a 10-year-old boy who was diagnosed with
for the following situations: autism spectrum disorder (ASD). His mother, a homemaker,
reported that Zachary was born full-term with no birth
i. Sharing your findings with interprofessional
complications. She added that Zachary generally met devel-
team members
opmental milestones during his first year of life. At age 2,
ii. Sharing your findings with the family she began to notice that he had “awkward” movements and
iii. Sharing your findings with Cindy’s preschool did not use words. She homeschooled Zachary until age 9
teacher in an attempt to meet all of his needs. Although Zachary
iv. Sharing your findings with Cindy’s primary has been generally healthy, he has recently been diagnosed
care physician with rheumatoid arthritis and is sensitive to pain. This year
he began attending school and has been receiving special
 Interprofessional Frameworks of Pediatric Practice 27

education. Zachary is reportedly curious and very alert, but 12. Walker K. Play Matters: Engaging Children in Learning the Australian
he is challenged by his impulsivity, poor communication, Developmental Curriculum: A Play and Project Based Philosophy.
Camberwell, Victoria: ACER Press; 2007.
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with fine motor skills, such as using the computer. He also us about the ways young children learn. Educational Leadership.
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frustrated, he acts out with tantrums, aggressive behavior, 14. Shipley D. Empowering children. Play Based Curriculum for Lifelong
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15. Siraj-Blatchford I. Understanding the relationship between curricu-
lum, pedagogy and progression in learning in early childhood. Hong
Kong Journal of Early Childhood. 2008;7(2):6-13.
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Every Child. 2003;14(2):3.
17. Samuelsson P, Carlsson A. The playing learning child: Towards a
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Functioning, Disability and Health (ICF). World Health Organization
Research. 2008;5(6):623-641.
Web site. http://www.who.int/classifications/icf/en/. Accessed January
18. Parten MB. Social participation among preschool children. J Abnorm
24, 2017.
Soc Psychol. 1932;27(3):243-269.
2. Family Voices. Family-centered care. Family Voices Web site. http://
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Clifton Park, NY: Cengage Learning; 2004:4-7.
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20. Stucki G, Cieza A, Ewert T, Kostanjsek N, Chatterji S, Üstün
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T. Application of the International Classification of Functioning,
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4. US Department of Health and Human Services. Philosophy and
21. American Physical Therapy Association. Physical Therapist
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Examination and Evaluation: Focus on Tests and Measures. In: Guide
Gateway Web site. https://www.childwelfare.gov/topics/famcentered/
to Physical Therapist Practice. Alexandria, VA: American Physical
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Therapy Association; 2014. http://guidetoptpractice.apta.org/con-
5. Forry ND, Moodi, S, Simkin S, Rothenberg L. Family-Provider
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Relationships: A Multidisciplinary Review of High Quality Practices
22. Doran GT. There’s a S.M.A.R.T. way to write management’s goals and
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Issue Brief OPRE 2011-26a. Washington, DC: Office of Planning,
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25. American Occupational Therapy Association. Occupational therapy
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Three exercise therapy approaches. Phys Ther. 1986;66:1233-1238.
Section 3
Culturally Competent Pediatric Care
Catherine Rush Thompson, PT, PhD, MS

this effort in mind, physical therapists, occupational thera-

OVERVIEW pists, and speech-language pathologists play a critical role
in bridging the gaps between local communities (medical,
According to research, by 2060, 64% of children under educational, and societal) and the home through education,
the age of 18 in the United States are projected to belong advocacy, developmental expertise, advising, and resource-
to racial and ethnic minorities, as compared with 48% of fulness. Interprofessional collaboration between stakehold-
children in 2014.1 “Greater cultural competence of mental ers relies on the abilities of these therapists to maintain a cli-
health service providers is associated with better overall mate of mutual respect while communicating with children,
outcomes (access, participation, satisfaction, and service families, communities, and other health professionals in a
outcomes) for African American youth and their families.”2 responsive and responsible manner. Competent communi-
This increase in diversity in our communities necessitates cation and collaboration include the provision of culturally
preparing pediatric therapists to be culturally competent, a and linguistically appropriate services. The underlying spirit
process that is ongoing and deliberate. of this section is based on assumptions that closely align
Designed to engage the learner in ongoing reflection, this with the principles of family-centered care outlined in an
section develops, refines, and grows awareness of cultural earlier section and include the following assumptions:
competency and cultural and linguistic diversity. It also
• Assumption #1: Every child and family with which the
offers options for improving cross-cultural communication
allied health professional will have contact is unique.
and for supporting policies that facilitate culturally compe-
tent care. • Assumption #2: Every child’s and family’s values,
wants, and beliefs are respected, even when in conflict
with that of the allied health professional.
ROLES OF PEDIATRIC THERAPISTS • Assumption #3: All children and their families are to be
treated with dignity and respect.
Pediatric therapists aim to help children reach their • Assumption #4: The family is a valued member of the
maximum potential to function in all environments. With health care team.

Thompson CR. Pediatric Therapy:

An Interprofessional Framework for Practice (pp 29-42).
- 29 - © 2018 SLACK Incorporated.
30 Section 3

• Assumption #5: Cultural competence is not something pediatric therapists need to be able to establish and maintain
that the individual obtains; cultural competence is partnerships with diverse constituency groups that span the
an ongoing process that constantly keeps each person boundaries of the traditional health and mental health care
engaged in exploring her or his own beliefs, biases, val- arenas to eliminate racial and ethnic disparities. This con-
ues, and assumptions and how these ideas influence and tinuum has been used across disciplines to serve as a model
shape interactions with other professionals, families, of developing cultural competence, and ultimately cultural
children, and others they aim to influence. proficiency, at both the individual and institutional level
All pediatric therapists need to engage in ongoing efforts (Table 3-1).
to increase their cultural competence to provide family- This continuum suggests that the lack of cultural
centered care that meets each child’s needs in cross-cultural competency (ie, culturally incompetent attitudes, policies,
situations. Ultimately, the role of this developing team cul- structures, and practices) can hinder the provision of care
ture is the achievement of successful outcomes for the child, across cultures. The learner is encouraged to reflect on
the family, and the communities in which they live. One key personal and team cultural competence: At what level are
ingredient for achieving these team outcomes is an inten- you personally? At what level on the continuum would you
tional effort to increase cultural and linguistic competence. consider your pediatric team? One important role of pediat-
ric therapists is to serve as facilitators in the development of
cultural competence impacting families, organizations, and
society at large.
CULTURAL AND LINGUISTIC In addition, helping all team members understand com-
COMPETENCE mon terminology is a positive step toward developing cul-
tural competency. For example, the word culture is thought
What is cultural and linguistic competence? to be synonymous with race and ethnicity; however, culture
encompasses much more than just race and ethnicity and
Cultural and linguistic competence is a set of congru-
includes such aspects as nationality, religion, spirituality,
ent behaviors, attitudes, and policies that come togeth-
and socioeconomic status. Culture is defined differently by
er in a system, agency, or among professionals that
many; however, central to the idea of culture is that it “is the
enables effective work in cross-cultural situations. Per
shared beliefs, values, traditions, assumptions, and lifestyles
the Cultural Competence Continuum, this capability
of a group of people.”6 Within this definition are several
involves ensuring that the needs of diverse patients/
variables that shape an individual’s culture. For example,
clients/customers are met by health service and public
several different words that are associated with cultural and
health organizations based on the acquisition of specif-
linguistic diversity and are encountered in pediatric settings
ic skill sets, valuing diversity, and taking concrete steps
include ethnicity, sexual identity, gender identity, national-
to ensure efficacy in serving [underrepresented and/or
ity, poverty, race, religious orientation, and stereotyping.
historically marginalized populations] populations.3
What is the difference between race and ethnicity? The
“Cultural and linguistic competence is as important to United States Office of Management and Budget set the
the successful provision of services as are scientific, techni- standard for classifying race and ethnicity within the United
cal, and clinical knowledge and skills.”4 This sentiment is States.3 These standards were put forth in part of an effort
echoed across all professions in the United States, given the to “collect data on the race and ethnicity of broad popula-
culturally diverse population of individuals from a variety of tion groups in this country, and are not anthropologically or
different cultural and linguistic backgrounds. scientifically based.”3,7,8 Although some may disagree with
these categories, they are used to describe various individuals
and groups, so pediatric professionals should have famil-
DEVELOPING CULTURAL COMPETENCE iarity with them.3 The definitions of race, ethnicity, and
nationality are provided in Table 3-2.
How is cultural competence developed? The Cultural The various ethnicities are further delineated in Table
Competence Continuum, proposed by Cross et al5 outlines 3-3, as defined by the United States Office of Management
the progressive development of cultural competence from and Budget.8 It should be noted, however, that there are
cultural incapacity in its earliest stages to cultural profi- social implications behind these categories that have a major
ciency, involving advocacy for societal changes to support influence on how individuals are able to participate in the
cultural diversity and cultural competency. Cultural pro- societies in which they live. Although it is understood that
ficiency can be achieved once a therapist is able to under- race is a social construct, historically and contemporarily
stand, appreciate, and accept different cultures based on used to create a hierarchy among the races, it must also be
an in-depth knowledge of cultural variations. Ultimately, understood that despite this absence of an anthropological
and social basis for race, these identifiers are associated with
 Culturally Competent Pediatric Care 31

TABLE 3-1
CULTURAL COMPETENCE CONTINUUM
Cultural destructiveness is characterized by attitudes, policies, structures, and practices within a system or
organization that are destructive to a cultural group.
Cultural incapacity is the lack of capacity of systems and organizations to respond effectively to the needs,
interests, and preferences of culturally and linguistically diverse groups. Characteristic include, but are not
limited to, institutional or systemic bias; practices that may result in discrimination in hiring and promotion;
disproportionate allocation of resources that may benefit one cultural group over another; subtle messages
that some cultural groups are neither valued nor welcomed; and lower expectations for some cultural, ethnic,
or racial groups.
Cultural blindness is an expressed philosophy of viewing and treating all people as the same. Characteristics of
such systems and organizations may include policies and personnel who encourage assimilation; approaches
in the delivery of services and supports that ignore cultural strengths; institutional attitudes that blame
consumers (individuals or families) for their circumstances; little value placed on training and resource
development that facilitate cultural and linguistic competence; workforce and contract personnel that lack
diversity (eg, race, ethnicity, language, gender, age); and few structures and resources dedicated to acquiring
cultural knowledge.
Cultural precompetence suggests that an organization is aware of its strengths and areas of growth for
responding to culturally and linguistically diverse populations. Characteristics include, but are not limited to,
the system or organization expressly valuing the delivery of high-quality services and supports to culturally and
linguistically diverse populations; commitment to human and civil rights; hiring practices that support a diverse
workforce; the capacity to conduct asset and needs assessments within diverse communities; concerted
efforts to improve service delivery, usually for a specific racial, ethnic, or cultural group; tendency for token
representation on governing boards; and no clear plan for achieving organizational cultural competence.
(continued)

both negative (eg, disenfranchisement, marginalization, belonging to a minority group are commonly excluded from
oppression) and positive (eg, healthy ethnic/racial identity full participation in the life of a society.6,9
development, cultural connection, tradition, and pride) fac- Although some individuals whom the therapist will
tors that play into one’s experiences, both perceived and encounter continue to use the terms minority and major-
real. Whether or not the impact of these experiences is in ity, many health professionals have moved away from this
any individual’s conscious awareness, it is important for the language in preference for language that more specifically
therapeutic team to be mindful of them because they will highlights the experience of the individual (eg, underrep-
play a role in their conceptualization of the family they are resented, historically marginalized, and targeted identities).
treating. Therapists interested in learning more about these terms
The use of the terms majority and minority provide are directed to explore the psychology of minoritization
illustration of how categories can influence an individual’s literature.
participation in society. These terms are sometimes used Therapists need to be sensitive to the differences in race
to denote the number of people; however, in the context and ethnicity of the families and children they serve. For
of cultural competency, the terms majority and minority example, federal policy defines Hispanic not as a race, but
denote who holds power and privilege, and conversely who as an ethnicity, yet 69% of young Latino adults 18 to 29
does not hold them, in a given society.6 Majority, or main- years say their Latino background is part of their racial back-
stream population, is defined as “the group [who] occupies ground, as does a similar share of those in other age groups,
a position of power and privilege.”6 Traditional standards of including those 65 and older.10 “At 54 million, Hispanics
“acceptable behaviors, values, and belief systems have been make up 17% of the nation’s population, and they are pro-
established by this group of people.”6 The minority group jected to grow to be 29% of the U.S. population by 2060.”11
is defined as the “group that is considered to be in a sub- Classifications of race and ethnicity in the United States are
ordinate position of prestige, power, and privilege.”6 People used for interpersonal interactions, accurate documentation,
and reliable research, so therapists need to be familiar with
32 Section 3

TABLE 3-1 (CONTINUED)

CULTURAL COMPETENCE CONTINUUM
Cultural competence is demonstrating an acceptance of and respect for cultural differences, including:
1. Creating a mission statement for the organization that articulates principles, rationale, and values for
cultural and linguistic competence in all aspects of the organization.
2. Implementing specific policies and procedures that integrate cultural and linguistic competence into each
core function of the organization.
3. Identifying, using, and/or adapting evidence-based and promising practices that are culturally and
linguistically competent.
4. Developing structures and strategies to ensure consumer and community participation in the planning,
delivery, and evaluation of the organization s core function.
5. Implementing policies and procedures to recruit, hire, and maintain a diverse and culturally and
linguistically competent workforce.
6. Providing fiscal support, professional development, and incentives for the improvement of cultural and
linguistic competence at the board, program, and faculty and/or staff levels.
7. Dedicating resources for both individual and organizational self-assessment of cultural and linguistic
competence.
8. Developing the capacity to collect and analyze data using variables that have a meaningful impact on
culturally and linguistically diverse groups.
9. Practicing principles of community engagement that result in the reciprocal transfer of knowledge and
skills between all collaborators, partners, and key stakeholders.
Cultural proficiency is holding culture in high esteem and using this as a foundation to guide all endeavors,
including:
1. Continuing to add to the knowledge base within the field of cultural and linguistic competence by
conducting research and developing new treatments, interventions, and approaches for health and mental
care in policy, education, and delivery of care.
2. Developing organizational philosophy and practices that integrate health and mental health care.
3. Employing faculty and/or staff, consultants, and consumers with expertise in cultural and linguistic
competence in health and mental health care practice, education, and research.
4. Publishing and disseminating promising and evidence-based health and mental health care practices,
interventions, training, and education models.
5. Supporting and mentoring other organizations as they progress along the Cultural Competence
Continuum.
6. Developing and disseminating health and mental health promotion materials that are adapted to the
cultural and linguistic contexts of populations served.
7. Actively pursuing resource development to continually enhance and expand the organization s capacities
in cultural and linguistic competence.
8. Advocating with, and on behalf of, populations who are traditionally unserved and underserved.
9. Establishing and maintaining partnerships with diverse constituency groups that span the boundaries of
the traditional health and mental health care arenas to eliminate racial and ethnic disparities in health and
mental health.
Adapted from Cross T, Bazron B, Dennis K, Isaacs M. Towards a culturally competent system of care, Volume I. Washington, DC: CAASP
Technical Assistance Center, Georgetown University Child Development Center, CASSP Technical Assistance Center; 1989.
 Culturally Competent Pediatric Care 33

TABLE 3-2
DEFINITIONS OF RACE, ETHNICITY, AND NATIONALITY
TERM DEFINITION
Race Some argue that race is a biological construct describing inherited anatomical features
and psychological attributes. Others argue that it is becoming a social construct. For the
purpose of this book, race refers a population with shared inherited traits and attributes.
Ethnicity The fact or state of belonging to a social group that has a common national or
cultural tradition.
Nationality The status of belonging to a particular nation. This status can be related to a place of
birth or through citizenship, generally governed by where the person reside.
Information compiled from Gannon M. Race Is a Social Construct, Scientists Argue. Scientific American Web site. https://www.scientificam-
erican.com/article/race-is-a-social-construct-scientists-argue/. Published February 5, 2016. Accessed March 30, 2017 and Oxford Dictionary.
https://en.oxforddictionaries.com/definition/ethnicity. Accessed March 30, 2017.

TABLE 3-3
CLASSIFICATIONS OF ETHNICITY IN THE UNITED STATES
ETHNICITY DESCRIPTION
Hispanic A person of Cuban, Mexican, Puerto Rican, Cuban, South or Central
American, or other Spanish culture or origin, regardless of race; the term
Spanish origin can be used in addition to Hispanic or Latino
Non-Hispanic A person not identifying with any of the origins considered Hispanic
Adapted from Standards for Maintaining, Collecting, and Presenting Federal Data on Race and Ethnicity. Centers for Disease Control and
Prevention Web site. https://wonder.cdc.gov/wonder/help/populations/bridged-race/OMB-RaceStandards1997.pdf. Published January 1,
2003. Accessed December 2, 2017.
Note: Although the terms Hispanic and Latino have been used interchangeably, Hispanic refers to individuals with heritage from the
Iberian Peninsula, whereas Latinos/Latinas are generally from Mexico, Central and South America, and the Caribbean.3

the correct description of each. Table 3-4 provides the cur- gained traction throughout the 1960s.12 Although some
rent classifications of race and their descriptions, and Table individuals continue to support the idea of the melting pot,
3-3 provides the classifications of ethnicity. When making far more identify with the idea that the United States is like
these designations, it is helpful to describe each term for a mosaic where people from different cultures come to the
future reference. United States, retain much of their unique culture, and still
Assimilation and acculturation are words that describe blend into the fabric of American society to create a rich
how people may choose, and in some cases are forced, to and unique culture.6 This is more indicative of the Cultural
incorporate themselves into different societies and cul- Pluralism Model, which gained prominence in the 1990s.12
tures.12 Assimilation is the process by which individuals give How, and if, a person choses to assimilate or acculturate
up their own culture in favor of assuming the attributes of may be influenced by several factors (eg, race, ethnicity, gen-
another culture, and acculturation is the process by which der, religion).12 Circumstances surrounding the immigra-
individuals take on the attributes of another culture.12 In tion may also greatly influence how a person integrates into
her research, Battle12 proposes three models that help to society.12 Battle12 states, for example, that people who iden-
explain the cultural and linguistic diversity in the United tify as voluntary immigrants may have more time to prepare
States. These models of assimilation and acculturation are for their transition into the new culture and, therefore, may
explained in Table 3-5. be more accepting of cultural changes that help them suc-
The Conformity Model has been used throughout the ceed in the new society. In contrast, involuntary immigrants
history of the United States; whereas the Melting Pot Model and those seeking asylum may not have time to prepare and
34 Section 3

TABLE 3-4
CLASSIFICATIONS OF RACE IN THE UNITED STATES
RACE DESCRIPTION
American Indian or Alaska Native A person having origins in any of the original peoples of North and South
America (including Central America) and who maintains tribal affiliation or
community attachment
Asian A person having origins in any of the original peoples of the Far East,
Southeast Asia, or the Indian subcontinent, including Cambodia, China,
India, Japan, the Koreas, Malaysia, Pakistan, the Philippine Islands, Thailand,
and Vietnam
Black or African American A person having origins in any of the Black racial groups of Africa
Native Hawaiian or Other Pacific A person having origins in any of the original peoples of Hawaii, Guam,
Islander Samoa, or other Pacific Islands
White A person having origins in any of the original peoples of Europe, the
Middle East, or North Africa
Adopted from Standards for Maintaining, Collecting, and Presenting Federal Data on Race and Ethnicity. Federal Register Web site. https://
www.federalregister.gov/documents/2016/09/30/2016-23672/standards-for-maintaining-collecting-and-presenting-federal-data-on-race-
and-ethnicity. Published September 30, 2016. Accessed on December 2, 2017.

TABLE 3-5
MODELS OF ASSIMILATION AND ACCULTURATION
MODEL DESCRIPTION
Conformity Model Ethnic minority group members within a larger society abandon their
own social, cultural, and personal traditions to take on the characteristics
and traditions of the dominant ethnic group.
Amalgamation (Melting Pot) All ethnic groups combine their traditions values and characteristics with
Theory one another to create a new group.
Accommodation Ethnic groups can coexist and still maintain their culture; they can also
(Cultural Pluralism) Theory comingle with the larger dominant group and maintain relative equality.

may even be outcast in the new society and, therefore, may communities Some of these terms are sensitive, and working
be more resistant to assimilation.12 with terms with variable definitions may be ineffective. Try
When pediatric therapists work with immigrant families, to decide on a common definition for team members for
they must be especially resourceful exploring their native improved communication and understanding among team
cultures to better understand their cultural beliefs, especially members and those served.
regarding children, families, education, and health. One of
the greatest barriers to providing culturally competent care
is language: speaking, listening, reading, and, most impor- DIVERSITY VERSUS
tantly, understanding the families who are seeking care.
Table 3-6 provides common terms related to culture. CULTURAL COMPETENCY
While not exhaustive, the list can be useful for self-devel-
opment by exploring, defining, and applying these com- In both health care and education, there is a push to con-
monly encountered terms to societal issues faced in local tinue to diversify the workforce in terms of race, ethnicity,
 Culturally Competent Pediatric Care 35

TABLE 3-6
CULTURAL TERMINOLOGY DEFINITIONS
OVERARCHING CONCEPTS
Culture The set of shared attitudes, values, beliefs, goals, and practices that characterizes group or
organization; the set of values, conventions, or social practices associated with a particular
field, activity, or societal characteristic
Ethnic Of or relating to large groups of people classed according to common racial, national, tribal,
religious, linguistic, or cultural origin or background
BACKGROUND/DEMOGRAPHICS/GENDER IDENTITIES
Androgynous Having the characteristics or nature of both male and female
Sex Either of the two major forms of individuals that occur in many species and that are
distinguished respectively as female or male especially on the basis of their reproductive
organs and structures
Gender The behavioral, cultural, or psychological traits typically associated with one sex
Generation A group of individuals born and living contemporaneously, eg,
• Gen Z, iGen, or Centennials: Born 1996 and later
• Millennials or Gen Y: Born 1977 to 1995
• Generation X: Born 1965 to 1976
• Baby Boomers: Born 1946 to 1964
• Traditionalists or Silent Generation: Born 1945 and before
Adapted from The Center for Generational Kinetics. Generational breakdown: Info about all of the generations. The Center for Generational
Kinetics Web site. http://genhq.com/faq-info-about-generations/. Published 2016. Accessed December 2, 2017.
Heritage Something that is handed down from the past, as a tradition: a national heritage of honor,
pride, and courage; something that comes or belongs to one by reason of birth; an inherited
lot or portion
Indigenous Growing, living, or occurring naturally in a particular region or environment (the indigenous
culture)
Nationality National status; specifically, a legal relationship involving allegiance on the part of an
individual and usually protection on the part of the state nationality bestowed by birth
Race A family, tribe, people, or nation belonging to the same stock; a class or kind of people
unified by shared interests, habits, or characteristics
ECONOMIC STATUS
Poverty The state of one who lacks a usual or socially acceptable amount of money or material
possessions
Privilege A right or immunity granted as a peculiar benefit, advantage, or favor
Socioeconomic One s access to financial, social, cultural, and human capital resources…the primary measurement
status of SES over the years has been the big 3 variables: (a) family income, (b) educational
attainment of heads of household, and (c) occupational status of heads of household
Adapted from Improving the Measurement of Socioeconomic Status for the National Assessment of Educational Progress: A Theoretical
Foundation. https://nces.ed.gov/nationsreportcard/pdf/researchcenter/Socioeconomic_Factors.pdf. Published November 2012.
Wealth An abundance of valuable possessions or money
(continued)
36 Section 3

TABLE 3-6 (CONTINUED)

CULTURAL TERMINOLOGY DEFINITIONS
SEXUAL ORIENTATION
Asexual A sexual orientation generally characterized by not feeling sexual attraction or a desire for
partnered sexuality; asexuality is distinct from celibacy, which is the deliberate abstention from
sexual activity; some asexual people do have sex
UC Davis. LGBTQIA Resource Center Glossary. UC Davis Web site. https://lgbtqia.ucdavis.edu/educated/glossary.html. Published October
13, 2017. Accessed December 2, 2017.
Bisexual Possessing characters of both sexes and especially both male and female reproductive
structures; of, relating to, or characterized by sexual or romantic attraction to members of both
sexes; also, engaging in sexual activity with partners of more than one gender
Cisgender Of, relating to, or being a person whose gender identity corresponds with the sex the person
had or was identified as having at birth
Gay/ Of, relating to, or characterized by a tendency to direct sexual desire toward another of the
Homosexual same sex
Heterosexual Of, relating to, or characterized by a tendency to direct sexual desire toward the opposite sex
LGBTQIA Lesbian, gay, bisexual, transgender, queer and/or questioning, intersex, asexual
Adapted from UC Davis. LGBTQIA Resource Center Glossary. UC Davis Web site. https://lgbtqia.ucdavis.edu/educated/glossary.html.
Published October 13, 2017. Accessed December 2, 2017.
Transgender A wide range of identities and experiences of people whose gender identity and/or expression
differs from conventional expectations based on their assigned sex at birth; not all trans people
undergo medical transition (surgery or hormones)
Adapted from UC Davis. LGBTQIA Resource Center Glossary. UC Davis Web site. https://lgbtqia.ucdavis.edu/educated/glossary.html.
Published October 13, 2017. Accessed December 2, 2017.

(continued)

and gender to create a workforce that looks like the clients

served. However, it is important to note that a pediatric
POLICIES, STANDARDS, AND
therapist working with a family from a culturally and/or lin-
guistically diverse background from her own does not need
MANDATES PROMOTING CULTURALLY
to be a member of that group to provide services to someone COMPETENT HEALTH CARE
of a different culture.6 Instead, it is more important that the
therapist have the skills and training necessary to deliver The importance of providing culturally competent health
services in an unbiased and culturally competent manner. and educational services has been underscored by the cre-
Pediatric therapists need to be very familiar with the ation and implementation of federal, state, and local govern-
idea of difference versus disorder.6 Difference and disorder are ment policies, accreditation standards, and other mandates
terms commonly used to describe children who are atypical aimed at reducing bias in service delivery, eliminating health
or different. A child who is different may be atypical due disparities, and improving the health of communities at
to cultural variability but not developmentally abnormal risk.3
or unhealthy. A child with a disorder may have a physical Medical cultural competency legislation and regulation
or mental condition that is not normal or healthy. The includes Title VI of the Civil Rights Act of 1964, a national
Interprofessional Activity section offers an opportunity to law that protects persons from discrimination based on their
explore difference versus disorder in the context of cultural race, color, or national origin in programs and activities that
differences that may impact a child’s developmental skills. receive federal financial assistance.13 In 2000, Executive
 Culturally Competent Pediatric Care 37

TABLE 3-6 (CONTINUED)

CULTURAL TERMINOLOGY DEFINITIONS
SOCIAL ATTITUDES/BELIEFS
Bigotry Obstinate or intolerant devotion to one s own opinions and prejudices
Classism Prejudice or discrimination based on class
Equality The quality or state of being equal
Hate Intense hostility and aversion usually deriving from fear, anger, or sense of injury; extreme dislike
or disgust
Micro- A comment or action that subtly and often unconsciously or unintentionally expresses a
aggression prejudiced attitude toward a member of a marginalized group (such as a racial minority)
Oppression Unjust or cruel exercise of authority or power
Power Ability to act or produce an effect; possession of control, authority, or influence over others;
physical might, mental or moral efficacy, political control or influence
Prejudice Preconceived judgment or opinion; an adverse opinion or leaning formed without just grounds
or before sufficient knowledge; an instance of such judgment or opinion; an irrational attitude
of hostility directed against an individual, a group, a race, or their supposed characteristics
Racism A belief that race is the primary determinant of human traits and capacities and that racial
differences produce an inherent superiority of a particular race
Sexism Prejudice or discrimination based on sex; especially, discrimination against women; behavior,
conditions, or attitudes that foster stereotypes of social roles based on sex
Stereotype An idea or statement about all of the members of a group or all the instances of a situation
Religion A body of beliefs and practices regarding the supernatural and the worship of one or
more deities
Spirituality The deepest values and meanings by which people live
Adapted from Sheldrake P. A Brief History of Spirituality. Hoboken, NJ: Wiley-Blackwell; 2007:1-2

Unless noted otherwise, definitions reprinted from Merriam Webster. Merriam Webster Web site. https://www.merriam-webster.com.
Published 2017. Accessed December 2, 2017.

Order 13166, Improving Access to Services for Persons In 2015, the Department of Health and Human Services
with Limited English Proficiency, required federal agencies enacted the Nondiscrimination in Health Programs and
to examine the services they provide, identify any need for Activities final rule that implements Section 1557 of the
services to those with limited English proficiency (LEP), and ACA.15 The Department of Health and Human Services
develop and implement a system to provide those services so states that the “final rule prohibits discrimination based
LEP persons can have meaningful access to them.13 on race, color, national origin, sex, age, or disability as
In 1995, the Center for Linguistic and Cultural well as enhances language assistance for individuals with
Competence in Health Care (CLCCHC) was established to limited English proficiency and protects individuals with
address the health needs of populations who speak limited disabilities.”16 The final rule was implemented in an effort
English and helps to fulfill the requirements of PL 101- to improve health equity and reduce disparities in health
527.14 CLCCHC is a “center without walls,” encompassing care. Essentially, the rule helps to provide protections from
all existing and new policy, partnerships, communications, discrimination in health care based on sex and provide
service demonstrations, and evaluation activities related to protections and access to individuals with disabilities and
cultural competency.14 individuals who have LEP.
The latest mandate to address culturally competent Although these policies are currently in place, they may
health care comes from the Affordable Care Act (ACA). not be recognized and enforced in some environments. As
38 Section 3

advocates for children and their families, pediatric therapists it is important to consider delivery of information in the
need to ensure that families are aware of their rights and language and medium most conducive to the child’s and
serve as advocates for support to ensure culturally competent family’s linguistic ability. The ACA prohibits discrimination
care for all. in health coverage and care based on race, color, national
origin, age, disability, and sex, so health care agencies must
provide appropriate interpretation and translation services
COMMUNICATING WITH when needed.17
Communicating with families with different languages
CULTURAL COMPETENCY has some ground rules that are important to consider. Here
are some key considerations when considering the use of an
Linguistics and language are words often used inter- interpreter19:
changeably in the cultural competence and cultural and • Use trained interpreters. Although it may often seem
linguistic diversity literature. In the context of diversity, easier, or even better, to have translation and/or inter-
linguistic diversity—or language diversity—refers to the pretation done by a member of the family, one must
number of languages and speakers of those languages in a not forget that the untrained person may not have been
given place (eg, the United States).17 The US Census Bureau exposed to medical or health care jargon and may not
(2015) reported there to be over 350 languages spoken in the be able to accurately convey the intended message;
United States households.18 Therefore, pediatric therapists there can be variations in dialect that may cause mis-
should expect to encounter individuals from linguistically understandings. In addition to being a potential Health
diverse backgrounds and be prepared to work with them. Insurance Portability and Accountability Act (HIPAA)
One culture commonly encountered in pediatrics is the violation, this practice puts both you and the family at
Deaf culture. Whereas the word deaf suggests someone risk for miscommunication and misinformation.
with hearing impairments, the Deaf culture (with a capital
• Use the “teach back” method: (1) ask the family to
“D”) refers to the attitudes, values, traditions, and history
repeat back what was just explained to them to assess
shared by this culture.19 According to the American Society
their understanding; (2) repeat your information, clari-
for Deaf Children, ample evidence supports the benefits of
fying as needed; then (3) ask the family to share what
using sign language with all children, regardless of their
they heard to confirm their understanding.
hearing status. The following are universal benefits of early
visual language20: • Talk directly to the family, not to the interpreter. Ask
• Early language learning experiences with sign language the family, “Do you…?” Speak more slowly rather
positively impact other areas of development and are than more loudly. Speak at an even pace in relatively
critical to children’s future success. short segments. Pause so the interpreter can interpret.
Assume, and insist, that everything you say, everything
• Sign language provides the earliest possible mode
the patient says, and everything that family members
through which children can learn expressive language
say is interpreted. Give the interpreter time to restruc-
skills.
ture information in his mind and present it in a cultur-
• All children benefit from the use of sign language with- ally and linguistically appropriate manner. Speaking
out any detriment to their other language skills. English does not mean thinking in English.
Because family involvement is a critical factor in the • Expect the interpreter to be a neutral party and to not
language development of children who have complete or take sides. The interpreter’s role is limited to facilitating
partial hearing loss, pediatric therapists should strive to sup-
linguistic and cultural communication between you
port a home environment that is linguistically accessible to
and the child and family.
a deaf child by encouraging parental use of sign language.
Therapists should also work as an interprofessional team to • Remember the cultural differences between you and
identify those signs that best serve the child’s and family’s the family. A family member may not answer questions
needs. In cases where a child has cognitive and/or motor as directly or clearly as you’d like, but that may be due
impairments, the interprofessional team can help the child to cultural differences in dealing with sensitive infor-
and family develop adapted signs for communication. mation. Ask the family member what she believes the
Translation and interpretation have important meanings problem is, what causes it, and how it would be treated
when working with families whose first language may not in their country of origin.
be English. Interpretation is providing a clear explanation of • Encourage the interpreter to ask questions and to alert
written words, whereas translation refers to the process of you about potential cultural misunderstandings that
translating spoken words3 or text from one language into may come up.
another. In the provision of culturally competent services,
 Culturally Competent Pediatric Care 39

• Ask the interpreter for clarification if you are unsure as A = Acknowledge and discuss the differences and
to his role. similarities.
• Recognize the limits of your bilingual skills.
R = Recommend a course of action.
• Do not ask the interpreter, “Do you think the family
understood?” The interpreter is not qualified to make N = Negotiate an agreement.
cognitive assessments. The interpreter’s role is to only Using the LEARN model enables pediatric therapists to
interpret, not to explain, simplify, alter, add, omit, or effectively communicate with each other, children, and oth-
summarize what is said. This helps keep the provider ers involved in the children’s care.
in control.
• Do not tell the interpreter, “Don’t interpret this, but….” The ETHNIC Model
It is a violation of his code of ethics. Remember that
the interpreter is required to interpret everything that Another model for working with families from diverse
is said within the patient’s earshot. If it is something an backgrounds goes by the acronym ETHNIC21 and serves as
another means of organizing cross-cultural communication:
English-speaking patient would hear, the foreign lan-
guage–speaking patient has the right to hear the same E = Explanation: Have the person describe what
information. he believes is the reason for the child’s problems.
• Do not ask the interpreter to interact with the family if Ask: What do you think may be the reason your
you are not present. child has these symptoms? What do friends and
family say about these symptoms? Do you know
• Avoid asking families if they understand. Individuals
anyone else with this problem? What have you
may be embarrassed to admit that they do not heard on the TV or radio about the condition?
understand.
• Keep in mind that interpreters are not advocates, social T = Treatments: Have the person share prior treatments
workers, health care providers, or family representatives. used to manage the child’s issues. Ask: What medicines,
When therapists work cross-culturally with families, it is home remedies, or other treatments have been tried? Is
helpful to: there anything you eat, drink, or avoid to stay healthy?
Please tell me about it. What treatment are you seeking?
• Take a few minutes to explain our health care culture
to the family. H = Healers: Consider that many cultures value alter-
• Speak clearly and slowly without raising your voice. native therapies and inventions. Ask: Have you used
• Use Mrs, Miss, and Mr for parents. Avoid using their alternative therapies or folk healers? Tell me about it.
first names, which may be considered discourteous in
N = Negotiate: Families may not be familiar with
some cultures. Always use the formal “usted” when
current options for addressing their concerns. At this
addressing parents/adult Spanish-speaking patients. point it is important to negotiate mutually accept-
• Avoid gestures: they may have a negative connotation. able options that incorporate the family’s beliefs
• Acknowledge beliefs. Some individuals believe their and those that offer the most benefit for the child.
child’s problems are caused by supernatural or envi-
ronmental factors like cold air or cold water. Do not I = Intervention: Consider how standard protocols
dismiss these beliefs because they play an important role may not be the best option for families who value
in some people’s lives. alternative interventions. Determine interventions
that respect the values and beliefs of each family.
The LEARN Model C = Collaboration: Recognize the importance of inter-
professional collaboration that integrates input from
Awareness of the family’s cultural background is criti-
the child, the family, therapists, other professionals,
cal to understanding the other person’s point of view and
alternative care providers, and community resources.
relevant issues. The LEARN model, emphasizing listening
and sharing similarities and differences, can be used to Pediatric therapists have the unique opportunity to meet
effectively overcome cultural communication barriers.20 and work with families where they are. This catchphrase is
The acronym LEARN represents the following key compo- often used to mean that the health care team should value
nents of the model20: and respect the needs, wants, abilities, and capacities of the
L = Listen with sympathy and understanding to the families they serve. Part of meeting families where they are
client’s perception of the problem. is an understanding of the family’s strengths. Strengths-based
approaches to therapy focus on what the child and family can
E = Explain your perceptions of the problem. do rather than what they cannot do.22-25 In the context of
40 Section 3

intervention, strengths-based approaches consider the child’s implement, and evaluate culturally and linguistically
skills rather than his limitations. These skills are then used competent service delivery systems to address grow-
as a basis for implementing compensatory strategies and ing diversity and persistent disparities and to promote
interventions. In the context of families, strengths-based health and mental health equity. https://nccc.george-
approaches consider what the family’s abilities are in terms town.edu/
of caring for the child. 6. CultureVision—A comprehensive, user-friendly data-
Finally, pediatric therapists must serve as advocates for base offering information about culturally competent
cultural competency, ensuring that public policies and laws care. http://www.crculturevision.com/
support access to resources that help people of all cultures 7. Cultural Competency for the Health Professional, by
who seek health care services in the United States. Listed Patti R. Rose.
here are resources that provide additional cultural compe-
tency information for self-assessment, professional develop-
ment, population specific care, and advocacy.
SUMMARY
As mentioned in earlier sections, pediatric therapists who
RESOURCES FOR CULTURAL work with family members must value family-centered care.
COMPETENCY Family-centered care respects families’ values, beliefs, and
ideas and attempts to integrate families’ wishes and goals
1. Health Resources and Service Administration: into therapeutic interventions to reach desired outcomes.
Culture, Language, and Health Literacy—This site For this reason, pediatric therapists must collaboratively
lists essential health literacy tools and resources for work toward becoming culturally competent clinicians and
distinct populations, including race/ethnicity, gender, educators; be open to other points of view and avoid value
age, and special populations. https://www.hrsa.gov/ judgments; treat everyone with dignity and respect; and
culturalcompetence/index.html use a strengths-based approach, recognizing each family’s
unique strengths as a basis for assessment, intervention, and
2. US Department of Health and Human Services education. Also, when managing care, pediatric profession-
Office of Minority Services: Cultural and Linguistic als need to be sensitive to their workplace’s character and
Competency—This site provides links to the National personality, also referred to as the workplace culture. Section
CLAS Standards, including a collective set of man- 4 will discuss how the workplace culture shapes interprofes-
dates and guidelines that inform, guide, and facilitate sional teamwork.
both required and recommended practices related
to culturally and linguistically appropriate health
services. It also links to the Center for Linguistic and
Cultural Competency in Health Care that addresses INTERPROFESSIONAL ACTIVITIES
the health needs of populations who speak limited
English. https://minorityhealth.hhs.gov/omh/browse. Your Cultural Identity
aspx?lvl=1&lvlid=6
Reflect on your cultural competency in light of the infor-
3. US Department of Health and Human Services: mation presented in this section.
Tracking CLAS—This interactive map displays each
1. What are your cultural identities, and what defines
state’s efforts to promote and provide culturally and
you the most? (Facets of your cultural identity may
linguistically appropriate services (CLAS) through
include, but are not limited to, your nationality,
legislation, policies, and/or practices. https://www.
ethnicity, native language and other languages, race,
thinkculturalhealth.hhs.gov/
gender, religion or spiritual beliefs, occupational sta-
4. Guide to Providing Effective Communication and tus, educational status, economic status or social class,
Language Assistance Services—This government site physical attributes, relationship status, age group, gen-
features a guide designed for health care profession- eration, geographical/regional residency, health status,
als, administrators, and executives who work across a and personality.)
broad spectrum of health care organizations. Register
2. How do your cultural identities impact how you react
for this guide and additional free resources at https://
with others?
hclsig.thinkculturalhealth.hhs.gov/
3. How would you rate yourself on the Cultural
5. National Center for Cultural Competence—This
Competency Continuum?
site offers resources to increase the capacity of health
care and mental health care programs to design,
 Culturally Competent Pediatric Care 41

Cultural Competency in Communication dominant, but Amena does not show any dominance when
coloring. Amena uses her thumb and all 4 fingers to grasp
Consider how diversity in families can impact how you objects and turn pages. She has difficulty following simple
will interact professionally with children and their families. tasks. She does vocalize with other children at the preschool.
1. Read the following case studies and discuss how the Her developmental screens on average showed her functional
interprofessional team can interact most effectively skills at the 20-month developmental age when she was 36
with the child and the family. Consider whether or months old. The interprofessional team is working with a
not the RESPECT or ETHNIC method would be private preschool to provide needed supports and equipment
appropriate. to ensure that Amena has what she needs to optimally learn
2. What cultural factors might influence delays in each in the preschool environment.
child’s development?
3. As an interprofessional team, what resources would
you explore in preparation for reassessing this child’s REFERENCES
functional skills? See the resources listed in this
section. 1. Colby SL, Ortman JM. Projections of the size and composition of the
US population: 2014 to 2060, Current Population Reports, P25-1143.
Washington, DC: US Census Bureau; 2014. https://www.census.gov/
content/dam/Census/library/publications/2015/demo/p25-1143.pdf.
Published 2014. Accessed January 25, 2017.
2. Mancoske RJ, Lewis ML, Bowers-Stevens C, Ford A. Cultural compe-
tence and children’s mental health service outcomes. Journal of Ethnic
& Cultural Diversity in Social Work. 2012;21:195-211.
3. Rose PR. Cultural Competency for the Health Professional. Burlington,
Case 3-1: A 13-month-old girl from China MA: Jones & Bartlett; 2013.
4. Cultural Competence. American Speech-Language-Hearing
Bo lived in an orphanage in Beijing, China, until she was Association Web site. http://www.asha.org/PRPSpecificTopic.aspx?fol
adopted by her American parents and brought to the United derid=8589935230&section=References. Accessed February 28, 2017.
States when she was 10 months old. Her parents, Mary and 5. Cross T, Bazron B, Dennis K, Isaacs M. Towards a culturally com-
petent system of care, Volume I. Washington, DC: CAASP Technical
Suzanne, also have 3 other recently adopted children, Grace
Assistance Center, Georgetown University Child Development
(a 5-year-old daughter from Ecuador), Bryan (a 7-year-old Center, CASSP Technical Assistance Center; 1989.
son from Guatemala), and Cam (a 9-year-old daughter from 6. Coleman TJ. Clinical Management of Communication Disorders in
Vietnam). Mary is a housewife who takes care of the chil- Culturally Diverse Children. Old Tappan, NJ: Pearson; 1999.
dren, and Suzanne runs a successful business that frequently 7. US Department of Health and Human Services Office of Minority
Health. Race. United States Census Bureau Web site. https://www.
takes her out of town. Bo is currently 13 months old; how-
census.gov/quickfacts/meta/long_RHI225215.htm. Accessed March
ever, her developmental skills are at the 6-month level of 30, 2017.
development. Both parents are interested in receiving private 8. Ford C, Harawa NT. A new conceptualization of ethnic-
services for Bo to help her gain the skills needed to catch up ity for social epidemiologic and health equity research. Soc Sci Med.
with her peers. 2010;71(2):251-258.
9. Essential principles in history. Democracy Web Web site. http://
democracyweb.org/majority-rule-principles. Accessed March 30, 2017.
Case 3-2: A 3-year-old girl with 10. Gonzalez-Barrera A, Lopez M. Is being Hispanic a matter of race,
developmental delay ethnicity or both? Pew Research Center Web site. http://www.
pewresearch.org/fact-tank/2015/06/15/is-being-hispanic-a-matter-of-
Maher and Aroos, Amena’s father and mother, immi- race-ethnicity-or-both/. Published 2017. Accessed January 25, 2017.
grated to the United States from Afghanistan when they 11. US Census Bureau. 2014 National Population Projections: Summary
Tables. United States Census Bureau Web site. http://www.census.
discovered that Amena was not developing like other gov/population/projections/data/national/2014/summarytables.html.
children her age. Both parents are professionals and very Accessed January 25, 2017.
religious. As Muslims, they feared that their family would 12. Battle B. Communication Disorders in Multicultural Populations. 4th
be shamed if they remained in Afghanistan, so both parents ed. Maryland Heights, MO: Mosby; 2011.
found secure jobs in technology. At 3 years, Amena is now 13. Limited English Proficiency. Executive Order 13166. Limited English
Proficiency Web site. https://www.lep.gov/13166/eo13166.html.
integrated into a half-day private preschool program. Amena Accessed January 25, 2017.
is able to walk but demonstrates poor balance, a wide base 14. US Department of Health and Human Services Office of Minority
of support, and high guard arm position when ambulat- Health. Center for Linguistic and Cultural Competency in Health
ing. Amena can kick a ball, but falls once with 3 kicks. Care. US Department of Health and Human Services Office of
She ascends and descends stairs in marking time with both Minority Health Web site. https://minorityhealth.hhs.gov/omh/
browse.aspx?lvl=2&lvlid=34. Accessed January 25, 2017.
hands holding onto the rails. Amena demonstrates palmar
grip around all objects. Her mother states she is left-hand
42 Section 3

15. US Department of Health and Human Services. Section 1557: 20. National Science Foundation. Visual and visual learning brief: advan-
Ensuring Meaningful Access for Individuals with Limited English tages of early visual language. American Society for Deaf Children
Proficiency. https://www.hhs.gov/sites/default/files/1557-fs-lep-508. Web site. http://deafchildren.org/wp-content/uploads/2014/05/
pdf. Published August 25, 2016. Accessed December 2, 2017. ASDC-Article-V L2-Advantages-of-Early-Visual-Language.pdf.
16. US Department of Health and Human Services. Strategic Language Published January 2012. Accessed February 28, 2017.
Access Plan. Centers for Medicare & Medicaid Services Web 21. American Translators Association. https://www.atanet.org/. Accessed
site. https://www.cms.gov/About-CMS/Agency-Information/ January 25, 2017.
OEOCR Info/Downloads/StrategicL a ng ua ge AccessPla n.pd f. 22. Welch M. Enhancing Awareness and Improving Cultural Competence
Accessed January 25, 2017. in Health Care: A Partnership Guide for Teaching Diversity and Cross-
17. Rumbaut RG, Massey DS. Immigration and language diversity in the Cultural Concepts in Health Professional Training. San Francisco:
United States. Daedalus. 2013;142(3):141-154. University of California.
18. US Census Bureau. Census Bureau Reports at Least 350 Languages 23. Levin SJ, Like RC, Gottlieb JE. ETHNIC: A Framework for
Spoken in U.S. Homes. United States Census Bureau Web site. Culturally Competent Clinical Practice. In: Appendix: Useful clinical
https://www.census.gov/newsroom/press-releases/2015/cb15-185. interviewing mnemonics. Patient Care. 2000;34(9)188-189.
html. Published November 03, 2015. Accessed December 28, 2017. 24. Hoagwood KE, Olin SS, Kerker BD, Kratochwill TR, Crowe M, Saka,
19. Minnesota Department of Health and Human Services. Deaf cul- N. Empirically based school interventions targeted at academic and
ture. Minnesota Department of Health and Human Services Web mental health functioning. J Emot Behav Disord. 2007;15(2):66-92.
site. http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_ 25. Reddy LA, DeThomas CA, Newman E, Chun V. School-based
DYNAMIC_CONVERSION&RevisionSelectionMethod=Latest prevention and intervention programs for children with emotional
Released&dDocName=id_004566. Published February 11, 2013. disturbance: A review of treatment components and methodology.
Accessed February 28, 2017. Psychology in the Schools. 2009;46(2):132-153.
Section 4
Overview of Human Growth and
Development for Pediatric Therapists
Catherine Rush Thompson, PT, PhD, MS

feeding. Sharing a similar knowledge of typical growth and

OVERVIEW development provides a foundation for interprofessional col-
laboration and appreciation of each professional’s expertise
The developmental framework for pediatric therapy when caring for children and educating their caretakers.
is similar across professions; however, each professional This section provides references to typical growth and devel-
focuses on different aspects of dynamic changes in a child’s opment that help guide the management of children with
growth and development. For example, when working with special needs. It also offers a reference for interprofessional
a child, the physical therapists might attend more closely collaboration and sets the stage for comprehensive goals that
to the growth and development of body systems and body address a child’s learning and healthy development. Finally,
functions, as well as the child’s ability to learn and perform it provides a guide to caretakers interested in providing age-
motor skills related to postural control and functional move- appropriate stimulation for their children.
ments. The occupational therapist might look more closely
at the child’s sensorimotor integration and engagement in
daily activities, such as eating and dressing, keeping in mind
similar motor learning factors. The speech-language pathol- GROWTH AND DEVELOPMENT
ogist might examine the child’s swallowing and communi-
cation skill development more closely. All 3 experts might All pediatric therapists aim to enhance children’s par-
observe the child’s snack time with attention to different ticipation in learning opportunities, social engagement,
aspects of this daily activity. The physical therapist would and meaningful lives. Fundamental to this goal is an
attend to the child’s posture for optimizing motor control understanding of typical growth and development. This
and providing a good base of support for feeding. The knowledge helps families and professionals identify concerns
occupational therapist would examine the task of feeding and collaboratively generate interventions and resources to
itself, noting fine motor and oral motor control for feeding. support the healthy growth and development of children
The speech-language pathologist would attend closely to the from birth through adulthood. Although the terms growth
child’s safety for oral feeding, including risk of aspiration, and development are often used interchangeably, they have
and would provide opportunities for communication during distinct meanings for pediatric therapists. Growth generally

Thompson CR. Pediatric Therapy:

An Interprofessional Framework for Practice (pp 43-70).
- 43 - © 2018 SLACK Incorporated.
44 Section 4

refers to the process of the child’s body increasing in physi- as when a child experiences growth spurts. Similarly,
cal size, as well as the increase in structures associated with development milestones follow a predictable pattern
body systems. Development refers to the child’s maturation, that is sequential, building on prior skills. However,
involving increasingly complex body functions and the dif- variations in this predictable pattern can occur when a
ferentiation of functional skills over time. Both growth and child focuses on a new milestone, sometimes causing a
development must be carefully monitored to ensure that regression in his performance of certain earlier skills.
each child’s environment (eg, the psychosocial and physi- • General to specific: The principle of general to specific is
cal environment) is optimal for the development of age- seen in both growth and development. During the first
appropriate skills. months of gestation, the fetus’ limbs are not well differ-
entiated; however, the fingers and toes become clearly
distinguishable as the fetus approaches full gestation. In
PRINCIPLES OF GROWTH AND terms of development, early movements employ larger
muscle groups, resulting in inaccurate and uncoordinat-
DEVELOPMENT ed movements. As the infant matures, smaller muscle
groups are activated for increased control for refined
Physical growth occurs concurrently with the develop-
movements. For example, an infant may initially swipe
ment of functional skills. Without an environment that
at a mobile but later develops the ability to accurately
encourages exploration, movement, and communication, a
point at objects with a single digit, evidence of develop-
child’s mental, psychosocial, and physical growth can suffer.
ing eye-hand coordination.
Assuming that children are reared in healthy environments,
maintain good health, and engage in physical activity, they • Proximodistal development: This principle states that
grow in predictable patterns.1 Using these predictable pat- development proceeds from the center of the body out-
terns to inform critical thinking, pediatric professionals ward. During growth in utero, the spinal cord begins
can monitor growth and anticipate children’s needs. These developing before the limbs. Similarly, a child develops
predictable patterns, commonly referred to as the principles motor control of the trunk (proximally), then gradually
of growth and development, include the following: refines movement at the periphery, as she demonstrates
• Simple to complex: The body develops from simple, control of her fingers (distally).
undifferentiated cells to highly differentiated organs • Maturation: This principle states that biological growth
and body structures. Likewise, a child’s functional skills and development depend upon maturation (eg, biologi-
become more sophisticated and complex with develop- cal growth and changes in the nervous system contrib-
ment. For example, an infant develops basic cognitive ute to increasingly complex cognitive and motor skills).
concepts early in childhood, then later demonstrates Maturation is innate, yet the development of skills relies
the ability to solve problems and use abstract thinking, upon environmental stimulation. For example, a child
requiring a more sophisticated level of intellect. must mature to a certain level of readiness to talk, com-
• Cephalocaudal development: This principle states that prehend words, and read. Similarly, legibly writing one’s
the direction of growth and development occurs from name requires fine motor control that develops through
the head downward, or head to toe. Examples of this experiences involving repeated motor practice.
principle include how a child gains control of move- • Individual rates: Perhaps the most important principle
ment, beginning with head control, followed by coor- that pediatric therapists recognize is that each child is
dination of the arms, then coordination of the legs. unique and, although these patterns are often observed
Another example of how the body grows head to toe can in a sequential pattern, the rates of growth and develop-
be observed by the changing head proportions (eg, head ment vary from child to child. For this reason, growth
circumference) with growth; the head is typically dis- charts provide a range of normal height and weight.
proportionately larger as a body part in infancy. Later Similarly, motor milestones occur across a wide range
in childhood and adolescence, the head circumference of ages depending upon environmental factors, includ-
stabilizes in size, whereas the trunk and legs grow in ing parenting styles, lifestyle behaviors, personal factors,
spurts, typically matching adult proportions by 21 years. and environmental enrichment.
• Continuous process: The process of growth and devel- These principles are helpful for recognizing patterns of
opment is continuous with a predictable sequence. growth and development for the typical child and are clearly
Although it is continuous, there is some variation, such evident in the first year of life.
 Overview of Human Growth and Development for Pediatric Therapists 45

from mass grasp patterns to isolated finger movements,

KEY FEATURES OF GROWTH IN THE including finger opposition by 12 months. These advances
FIRST YEAR OF LIFE are matched by increased control in oral motor skills that
enable the child to first vocalize and then to utter her first
Growth is a dynamic process that is dependent upon words by 1 year.
a child’s genetics and movement. Muscle growth and the During the first year of life, the infant experiences dra-
development of muscle strength and control of joint move- matic changes in growth and development, dependent upon
ment are all critical for a child to fully develop motor skills a healthy environment, opportunities for movement against
for independence. With the earliest movements, the child’s gravity, and social interactions with parents and other care-
skeletal muscle fibrils grow by multiplication, increas- takers. The brain maturation process evolves as synapses
ing strength to meet the demands of future movement. form, nerves myelinate, and the brain’s efficiency increases
Simultaneously, skeletal muscles lengthen or stretch in through synaptic pruning, improving the child’s sensory
response to skeletal growth, allowing more range of motion. integration and motor control.2 The brain develops into
For children with motor problems restricting movement, separate lobes associated with specific functions, including
skeletal muscles may not reach their full length, potentially the occipital lobes that control vision; the parietal lobes
restricting future motor development. Similarly guided by processing bodily sensations like heat, cold, pressure, and
genetic codes, cells of the visceral muscles (ie, smooth, invol- pain; and the temporal lobes involved with hearing, lan-
untary muscles lining the blood vessels, stomach, digestive guage skills, and social understanding, including perception
tract, and other internal organs) increase in number and of other people’s eyes and faces. Finally, the frontal lobes,
size throughout the growth process. The cardiac muscle, associated with memory, abstract thinking, planning, and
like skeletal muscle, is responsive to the body’s demands for impulse control, are the last to mature. These lobes include
increased circulation during activity, resulting in enlarge- the prefrontal cortex, associated with the most advanced
ment of existing muscle fibers, particularly in ventricular cognitive functions, including attention, motivation, and
muscles. goal-directed behavior.3-5
In accordance with the cephalocaudal principle of devel- The growth and development of body systems across
opment, the infant develops functional skills for survival. infancy, childhood, and adolescence exemplify the prin-
From early infancy, the muscles of the face and respiration ciples of growth and development discussed previously.
are well developed, allowing the newborn to breathe, feed, Whereas genes help direct newly formed neurons to their
and vocalize at birth, assuming the child is born full term. correct locations in the brain, brain connections are rein-
Typically at birth, after spending 9 months positioned in the forced or modified by infant and child behavior.6-8 During
womb, the neonate is positioned in a predominantly flexed the infant’s active exploration of the environment, the
posture. In the womb, the fetus was not positioned to allow neurological and musculoskeletal systems work in concert
neck extension in the last trimester, so the strength of cervi- to enable postural control for handling toys and uttering
cal muscles is poor. Once out of the womb, the newborn meaningful sounds. As early as 6 months, protective reac-
wants to see the world. As the newborn moves spontaneously tions emerge, and by 12 months, equilibrium reactions in an
and experiences the effects of gravity, the second month of upright posture enable the infant to stand unsupported for
life is typically characterized by decreased postural flexion play. By 1 year, the infant is typically able to communicate
and increased extension and asymmetry, generally progress- through gestures and sounds, demonstrate intent by point-
ing from head to toe. For example, the infant begins to raise ing at objects, appreciate object permanence, and manually
her head against gravity to either side when placed in a prone feed herself, among many other skills. Table 4-1 illustrates
position as she visually explores her surroundings. the growth and development of body systems in the first
During the third month of life, the infant’s movements year of life.
are characterized by more symmetrical movements, includ-
ing the beginning of bilateral control of neck muscles, facili-
tating head control. At this point, the infant initiates rolling GROWTH THROUGHOUT CHILDHOOD
in both direction and swipes at toys held within reach. By 6
months, the infant can extend her neck against gravity when Activities during early childhood further drive the devel-
lying prone, can roll, and can sit with minimal support. By opment of body systems to respond to the stresses imposed
7 months, the infant can pivot in prone using symmetrical on tissues. The child’s health and growth are monitored
upper-extremity movements, and by 8 months, the baby can from birth to adulthood by physiological markers, such
creep as the primary means of locomotion. At 1 year, the as blood pressure and respiration, and by anthropometric
baby is capable of rising to stand by using her developing measurements (eg, head circumference, height, and weight)
leg muscles. Simultaneously, fine motor control progresses recorded on growth charts. Table 4-2 describes the changes
 TABLE 4-1 46

TYPICAL GROWTH AND DEVELOPMENT OF BODY SYSTEMS FROM BIRTH TO 1 YEAR

AGE MUSCULOSKELETAL NEUROLOGICAL/ CARDIOPULMONARY INTEGUMENTARY
Section 4

COGNITIVE
Birth • Neonate: physiological flexion • Neonate: flexion→extension • Rapid heart rate, • Intact
to 6 • Pronated feet • The spinal cord is about respiratory rate • As the skin
months • Genus valgus 15 to 18 cm long grows, the
• Primary centers of ossification are present in all • Myelinization continues in sensory
long bones both the periphery and the endings
cerebral cortex become
• Fontanelles are present in the skull (these are non-
• Primitive (spinal cord and thinned out
serrated sutures)
brainstem) reflexes are and not as
• Skull vault is large closely packed
present at birth
• Secondary centers of ossification present in lower
end of femur, heads of femur and humerus, and • Optical righting reflex starts
upper end of tibia to develop at 2 months
• Bones of the pelvis and lower limbs are less • Sensorimotor integration
advanced as far as final size than those of the
upper limbs and shoulder girdles
• Ilia and sacrum are more upright, and subpubic
angle is more acute so cavity of pelvis is small and
funnel shaped
• At 6 months, the mandibular incisors emerge
• At 6 months, the secondary cervical curve has
appeared
• Feet are flat, soft, subtle, difficult to appreciate due
to increased subcutaneous fat; lower extremity
range of motion is increased
7 to 12 • The skull follows the very rapid growth of the brain • Protective reactions emerge
months • The mastoid process forms in the skull at 6 months
• The capitate of the wrist starts to ossify • Righting reactions develop
• The growth in skeletal height is approximately • Equilibrium reactions
20 to 22 cm/year develop
• With walking, sacral curvature increases, ilia • Beginning of speech
become thicker, and acetabula become deeper patterns: single words
repeated
 Overview of Human Growth and Development for Pediatric Therapists 47

TABLE 4-2
SKELETAL CHANGES FROM 1 YEAR TO 6 YEARS
1 YEAR TO 3 YEARS 4 TO 6 YEARS
Spine and • Leg growth accelerates in the toddler years • Primary ossification centers
extremities • Height increases 5 inches in the second year and appear in the patella and the
2 inches during the third year carpal bones by 3 to 3½ years
• The structural changes of long bone are greatest at • Height increases from
2½ years 5 to 6 cm/year
Skull • All bones of the skull are ossified by 2 years
Dentition • By 6 years, the child has
developed the primary dentition
and has had some teeth replaced
by the secondary dentition
(permanent teeth)
Skeletal • Toddler stands bow-legged (genu varus) at 18 • At 3 years, nearly 75% of children
alignment/ months and nock-kneed (genu valgus) at 3 years develop genu valgum, which is
curvature because of remodeling of the pelvis resolved by 6 to 7 years
• With increased walking, lower limbs realign, feet
evert, and the angle made by the neck of the
femur with the shaft gradually decreases from
about 160 degrees to the adult value of
125 degrees

in the body alignment as a result of movement and illustrates adult size by 5 or 6 years.7 Table 4-4 outlines neurological
the changes in dentition that enable eating a wider variety changes impacting sensory, motor, and cognitive functions
of foods.7 from 2 to 6 years.
After the first year of life, muscles continue to grow and Adolescence is when children again undergo dramatic
develop in response to activity. Muscle fibers enlarge, pro- physical changes:
viding the strength needed for oral motor, fine motor, and The human adolescent growth spurt is the rapid and
gross motor skills. The child is able to walk, run, and jump intense increase in the rate of growth in height and
with increasing power and endurance, speak with increased weight that occurs during the adolescent stage of
volume and clarity, and more easily manipulate objects with the human life cycle. The human adolescent growth
varying grasp patterns. These dynamic changes are not spurt is noted in virtually all of the long bones of the
without some discomfort; children may experience growth body and most other skeletal elements. The major
pains during growth spurts.7 The child also develops the exception is the female pelvis, which follows a smooth
power to securely grip a spoon and self-feed. At this time, and continuous increase in size until adulthood.8
the sphincter muscles develop sufficiently to allow toilet
training. By 5 years, the child has adequate manipulation During adolescence, most boys and girls reach adult
skills to begin handwriting, and oral motor mechanisms are height and weight, although there is considerable variation
developed for clear articulation and chewing (Table 4-3). in when this occurs. In general, boys become heavier and
The most important system for learning is the neurologi- taller than girls, but their growth is later. Adolescent males
cal system, responsible for a child’s desire to explore and to experience a growth spurt between 13 and 15½ years; a gain
store information. Through play, the child’s nervous system of 4 inches can be expected in the year of maximum growth.
develops efficiency for sensory recognition, sensory inte- By 18 years, boys have about ¾ inch of growth remain-
gration, movement, language development, and cognitive ing, and girls have slightly less.8 Girls experience an earlier
functioning. The central nervous system and the organs of growth spurt between 11 and 13½ years; a gain of 3½ inches
special senses grow so rapidly that they reach 90% of their can be expected in the year of maximum growth.8 Height
48 Section 4

TABLE 4-3
MUSCULAR CHANGES FROM 1 YEAR TO 6 YEARS
1 YEAR TO 3 YEARS 4 TO 6 YEARS
Skeletal • Early in this stage, the muscular strength of the • Creatinine in urine increases as
muscles trunk and lower extremities increases to support muscle mass increases
bipedal locomotion • Muscle fibers increase in diameter
as strength increases
• Muscle strength increases as
activity increases
Cardiac • Muscles of the left ventricle of the heart grow
muscle more than the right to accommodate the increase
in workload
Sphincter • Sphincter muscles develop to allow toilet training
muscles

Postural • With continued weight bearing, the growth of • Muscle strength depends upon
patterns intrinsic feet muscles causes the once fat, thick, and body proportions; adult
associated archless foot to become arched with the normative values are not accurate
with muscle development of the longitudinal arch for children.
development • At 2 years, the toddler displays a mature grasp • Children may experience growth
pattern that enables prehension and the manual pains as muscle growth
exchange of objects accompanies bone growth
• By 5 years, children have adequate
manipulation skills to begin
handwriting

increases most before menstruation begins, as hormones At birth, typically following 40 weeks’ gestation, the
surge to develop reproductive systems. Also, the prefrontal newborn engages in interactions with the external world that
cortex does not fully mature until after 21 years, illustrating promote social engagement, movement, and play. Pediatric
that executive brain function (associated with the highest therapists carefully note these developmental milestones as
levels of planning, critical thinking, and problem solving) an indirect means of assessing the child’s neuromuscular
lags behind body growth. Table 4-5 outlines how body sys- function and potential for learning.
tems change from adolescence into adulthood.6 A newborn’s development is reliant upon her ability to
Knowledge of how the body systems grow and mature engage with the environment. How early is the newborn
provides a basis for understanding how the child is capable able to interact with the environment for learning? This
of achieving the typical motor milestones throughout child- question can be answered by looking at studies on the devel-
hood. The next section provides an overview of how skills opment of perception, or the ability to be aware of sensory
needed for functional independence are typically developed input. Studies on hearing have shown that the fetus can
and sequenced from birth to adulthood. perceive her mother’s voice while in utero.9,10 This percep-
tion of hearing is hypothesized as the reason that a newborn
tends to turn her head toward the source of sounds and dis-
DEVELOPMENTAL MILESTONES tinguishes her mother’s voice.9,10 Young infants also have a
keen sense of smell and can distinguish pleasant vs unpleas-
A child’s development is appraised through observations ant smells, preferring honey or chocolate to rotten eggs
of social interactions and achievement of developmental or fish.11 Similarly, newborns can differentiate salty, sour,
milestones. Even before birth, a mother should feel the fetus bitter, and sweet tastes, favoring sweets at birth, then prefer-
kicking and moving in her womb, an early indicator of ring salty tastes at 4 months.12 Prenatal flavor experiences
healthy growth and development.
 Overview of Human Growth and Development for Pediatric Therapists 49

TABLE 4-4
NEUROLOGICAL CHANGES FROM 2 TO 6 YEARS
1 YEAR TO 3 YEARS 4 TO 6 YEARS
Structure of • The brain growth spurt ends between • Nerve conduction rates increase as
the brain and 2 to 4 years, and, by the end of the second nerve fibers increase in diameter
spinal cord year it has doubled its birth weight • Peripheral nerves grow to keep pace
with growing bones and muscles
• Cortex modifies synapses as
cognitive function increases
• Little change in the cortical thickness
takes place after 4 years
Myelinization • During this stage, the motor (pyramidal) tracts
become completely myelinated
Sensory • At 2 years, the auditory pathways become • The central nervous system and the
myelinated organs of special senses growth
pattern is so rapid that they reach
90% of their adult size by 5 or 6 years
Motor • The child is able to control eye movements to • Coordination improves as the
track objects cerebellar function develops
Cognition • By 3 years, the child has a vocabulary of
approximately 900 words

enhance the acceptance and enjoyment of similarly flavored Whereas newborns can perceive only a few colors, by 3 to 4
foods during weaning.13,14 months, they are able to see the full range of colors.22
Touch is a sensation that relies on the sensory receptors Visual perception is key to the eye-hand coordination
in the skin, the largest sense organ and the first to develop.15 that the newborn begins to develop at birth. Through the
The fetus receives sensory input from the maternal womb, integration of sensorimotor experiences, the infant demon-
demonstrating increased activity when stimulated by the strates visually directed movements to explore her environ-
mother’s abdominal wall.15,16 The sense of touch is inte- ment through vision, touch, smell, hearing, and taste. This
gral to breastfeeding and handling, especially skin-to-skin early play lays the foundation for the development of spatial
contact between the mother and child, as facilitated in orientation, conceptualization, reading, spatial transforma-
kangaroo care.17 Touch can also be used to communicate, tion, and adult cognition.
conveying different emotions, not unlike facial and vocal Language development is complex but, in general, fol-
expressions.17,18 Touch deprivation in newborns and young lows a predictable, sequential pattern. However, although
infants, whether caused by time spent isolated in the neo- the pattern is predictable, there is a wide range of what is
natal intensive care unit or by a mother experiencing post- considered typical development during infancy and the
partum depression, can lead to later cognitive and neurode- toddler years. Beginning in infancy, children learn lan-
velopmental delays.19,20 These delays resulting from touch guage through a social context. While in the uterus, all the
deprivation appear to persist for many years.21 infant’s needs are met by the body of the mother. Upon
Vision is the least mature of all the senses at birth due birth, however, infants are dependent on caregivers to inter-
to the lack of visual stimulation in utero prior to birth. pret nonlinguistic cues such as crying, yawning, and other
Although vision is limited at birth, by 6 months, the infant’s reflexive sounds to have their needs met. Gradually over the
visual acuity approaches 20/25 and reaches adult visual acu- first year, infants develop intentional communication and
ity (20/20) by 1 year.22 At birth, infants have the greatest ultimately verbal language, but this is largely influenced by
sensitivity to intermediate wavelengths (yellow/green) and the environment (including caregiver responsiveness to these
less to short (blue/violet) or long (red/orange) wavelengths. early nonlinguistic cues).23
 50
Section 4

TABLE 4-5
GROWTH DURING ADOLESCENCE
STAGE MUSCULOSKELETAL NEUROLOGICAL/ CARDIOPULMONARY INTEGUMENTARY OTHER SYSTEMS
COGNITIVE
Adolescent • Growth spurts: males as early • Development: • Slowing of heart • Intact • Development
as 11, typically 13 to 15½; prefrontal cortex rate and respiratory of reproductive
females as early as 9, typically continues to rate systems:
11 to 13½ develop through hormonal surge
the 20s
Adult • Mature system: function • All neurological • All systems mature • Intact
contingent upon fitness functioning
mature
 Overview of Human Growth and Development for Pediatric Therapists 51

During the first years of life, in addition to learning the pattern of movement involving multiple joints and
specific language spoken by the family, children also learn muscles co-contracting.
the contexts in which communication occurs. During the • Early reflexes: This is a category of developmental reflex-
first 2 months, infants typically express themselves by bab- es that are apparent in fetal life that may contribute to
bling for pleasure and making their first vowel sounds at the movements that contribute to the development of motor
front of their mouth. By 3 months, infants can comprehend functions, such as sucking and grasping objects.
pleasure, anger, and fear by listening to the intonational
• Attitudinal reflexes: Attitudinal reflexes produce persist-
patterns of their parents and caretakers, depending upon
ing changes in body posture that result from a change
the situation in which the sounds are heard. Vocalizations
in head position.
might reflect similar intonations, but expressions in these
early months are often limited, and the infant may use any • Postural reflexes: Postural reflexes enable an infant to
variety of cries to communicate needs. By 6 months, infants increase muscle activation for support of body weight
are typically able to respond to words with some vocaliza- against gravity.
tions that approximate words, and, by 8 months, they • Righting reactions: Righting reactions allow the child to
begin to use increased inflection in vocal play, use elaborate bring the head and trunk into normal position in space
jargon, and make fluent sounds. At 8 months, infants are and in relation to the ground.
becoming more intentional with gestural communication, • Equilibrium reactions: These automatic reactions help
but it is not until 10 to 12 months that infants usually speak the child maintain or control the center of gravity.
their first words.23 It is believed that infants watch others • Protective reactions: These are reactions to protect the
carefully and make sounds that approximate what they
body when falling or when the head is placed in jeop-
hear. Language growth occurs by leaps and bounds follow-
ardy for injury.
ing their first words; by 18 months, most have a vocabulary
of 50 words and may be starting to combine words into • Tilting reactions: These automatic reactions tend to pre-
phrases.23 serve the equilibrium of the body under conditions of
The development of language, both receptive language instability of the supporting base.
(understanding what others say) and expressive language (the • Postural fixation reactions: These reactions automati-
ability to express information to others through words, ges- cally sustain and balance the person as a whole. The
tures, or writing), is foundational to understanding a child child’s body parts (head, trunk, and extremities) are in
and appreciating her needs. Delays in language development positions appropriate to the activity of the movement
can have a profound impact on psychosocial function and and to any external forces that may be acting on them.
family relationships. Because the fetus hears sounds in the • Integration of a reflex: Typically, early reflexes, including
womb during its last trimester, some researchers believe that the tonic attitudinal reflexes and the postural reflexes,
receptive language may begin before birth. If there is a hear- become integrated. In other words, the stimulus does
ing loss, however, language may be delayed. Fortunately, not elicit a stereotypical or predictable response con-
infants are usually screened for hearing loss at birth; if not, sistently. The integration of a reflex, noted when it is
the average age of detection of significant hearing loss is not predictable and consistently elicited, allows the
approximately 14 months.9 Table 4-6 provides the typical individual to move more voluntarily.
sequence of language development.
• Obligatory response: This type of response is a persistent,
Underlying the development of functional skills through- stereotypic response to a stimulus that should be inte-
out infancy and early childhood are developmental reflex- grated, suggesting atypical neuromotor development.
es24 that facilitate the development of motor skills. Pediatric
An obligatory response is a developmental red flag.
therapists should be familiar with each of these reflexes,
which are indicators of an infant’s neurological development Appendix A includes a detailed list of these devel-
and how the body responds to stimuli from the environ- opmental reflexes commonly used to assess neuromotor
ment. Terms used to describe the developmental reflexes development.24
include the following: The development of skills that are commonly used to
• Reflex: A reflex is an involuntary response. This type of assess infants and young children is outlined in Table 4-7.
These skills include gross motor skills, fine motor skills, oral
response occurs when a stimulus activates what is con-
motor skills associated with feeding and communication,
sidered an innate or involuntary movement associated
social and emotional skills, and cognitive skills. Pediatric
with nervous system function.
therapists should be familiar with all of these skills, recog-
• Reaction: A reaction may be demonstrated spontane- nizing the expertise of team members to assess areas of con-
ously by the infant, child, or adult and may also be elic- cern and to provide transdisciplinary care for comprehensive
ited by external stimuli. This response is a coordinated management of each child. It is also imperative to educate
52 Section 4

TABLE 4-6
NEUROLOGICAL CHANGES FROM 2 TO 6 YEARS
AGE RECEPTIVE LANGUAGE EXPRESSIVE LANGUAGE
5 mos • Listens to voices and watches face of speaker • Begins socialized vocalization with
cooing sounds
6 mos • Begins to understand highly familiar words • Babbles with reduplicated sounds:
(mommy, daddy) in context ba ba ba, da da da
9 mos • Understands the meanings of many words • Babbling becomes more complex with
varying sounds such as ba da ba
10 mos • Uses jargon that sounds like words with
intonation and inflection
• First word may begin to emerge
• Uses intentional gestures to communicate
12 mos • Understands simple questions: Where s • Uses a few words (2 to 6) consistently
Mommy? • Uses both words and gestures
• Responds to simple commands such as No
15 mos • Comprehends about 50 words • Expressive vocabulary of 10 words
• Indicates refusal by bodily protest
18 mos • Listens to stories • Expressive vocabulary of 50 words
• Points to familiar named objects in the • Begins to produce 2-word utterances
environment and in books • Verbalizes ends of actions: bye-bye, all gone
21 mos • Asks for food, bathroom, and drink
• Repeats words or short phrases
2 yrs • Understands what questions • Expressive vocabulary of 200 to 300 words
• Points to common objects when described: • Asks, What s that?
What do you use to brush your teeth? • Speech accompanies activities
• Verbalizes immediate experiences
(continued)
 Overview of Human Growth and Development for Pediatric Therapists 53

TABLE 4-6 (CONTINUED)

NEUROLOGICAL CHANGES FROM 2 TO 6 YEARS
AGE RECEPTIVE LANGUAGE EXPRESSIVE LANGUAGE
2½ yrs • Begins to produce 3-word phrases when
approximately half of utterances consist of
2-word phrases
• Demands to do things by self
• Gives full name
• Elicits: Look at me!
3 yrs • Follows 2-step directions • Begins to produce 4-word phrases when
• Begins to understand most wh questions approximately half of utterances consist of
3-word phrases
• Expressive vocabulary of 1000 words
• Interested in conforming: Is that right?
• Expresses limitations by can t or
I don t know
4 yrs • Understands most of what is said in • Talks about everything
conversation • Plays with words
• Questions persistently
• Elaborates simple responses into long
narratives
• Able to take turns in conversation
• Can tell a story combining real and
unreal features
• Tendency toward self-praise: I m smart,
I know everything
• Bosses and criticizes others
5 yrs • Understands instructions given by unfamiliar • Expressive vocabulary of 2200 to 2500 words
people • Begins to be aware of social standards and
• Understands the meaning of stories limitations with respect to language use
• Understands how things are same or • Adjusts language based on context and
different situation (may talk more slowly to a
• Follows 3-step directions younger child)
6 yrs • Normal comprehension of everyday • Uses most grammatical morphemes (eg,
language (slightly immature) plurals, possessives, past tense) appropriately
• Speech production is mostly adult-like, with
few developmental articulation
errors remaining
54 Section 4

TABLE 4-7 . TABL

DEVELOPMENT OF FUNCTIONAL SKILLS/ABILITIES FROM BIRTH TO 6 YEARS BIRT
GROSS MOTOR FINE MOTOR ORAL MOTOR AND
FEEDING
Birth to • Physiological flexion (birth) • Visual tracking • Rooting reflex
2 mos • Holds head up • Begins to follow • Suck reflex
• Begins to push up when things with eyes • Bite reflex
lying on tummy • Recognizes people at
• Makes smoother movements with a distance
arms and legs • Palmar grasp
• Traction reflex

4 mos • Holds head steady, unsupported • Can hold a toy and

• Pushes down on legs when feet are shake it and swing at
on a hard surface dangling toys
• May be able to roll over from tummy • Brings hands to
to back mouth
• When lying on stomach, pushes up
to elbows

6 mos • Rolls over in both directions (front to • Brings things to mouth

back, back to front)
• Begins to sit without support
• When standing, supports weight on
legs and might bounce
• Rocks back and forth, sometimes
crawling backward before
moving forward
• Muscle tone is neither stiff nor floppy

9 mos • Stands holding on • Moves things • Puts things in her mouth

• Can get into sitting position smoothly from one
• Sits without support hand to the other
• Pulls to stand • Picks up things like
cereal o s between
• Crawls
thumb and index
finger
 Overview of Human Growth and Development for Pediatric Therapists 55

LE 4-7 TABLE 4-7

TH D DEVELOPMENT OF FUNCTIONAL SKILLS/ABILITIES FROM BIRTH TO 6 YEARS
ORAL MOTOR AND SOCIAL AND EMOTIONAL COGNITIVE
COMMUNICATION
• Birth: Cries • Erikson: Basic trust vs mistrust • Pays attention to faces
• 2 mos: Coos, makes • Begins to smile at people • Begins to act bored (cries, fussy)
gurgling sounds • Can briefly calm himself (may if activity doesn t change
• Turns head toward sounds suck on hand) • Watches things move
• Tries to look at parent • Responds to loud noises
• Learns about self and
environment through motor
and reflex actions
• Derives thought from sensation
and movement
• Begins to babble • Smiles spontaneously, especially • Lets you know if she is happy or
• Babbles with expression and at people sad
copies sounds he hears • Likes to play with people and • Responds to affection
• Cries in different ways to might cry when playing stops • Reaches for toy with one hand
show hunger, pain, or • Copies some movements and • Uses hands and eyes together,
being tired facial expressions, like smiling such as seeing a toy and
or frowning reaching for it
• Follows moving things with eyes
from side to side
• Watches faces closely
• Recognizes familiar people and
things at a distance
• Responds to sounds by • Knows familiar faces and begins • Looks around at things nearby
making sounds to know if someone • Shows curiosity about things and
• Strings vowels together when is a stranger tries to get things that are out of
babbling ( ah, eh, oh ) and • Likes to play with others, reach
likes taking turns with parent especially parents • Begins to pass things from one
while making sounds • Responds to other people s hand to the other
• Responds to own name emotions and often
• Makes sounds to show joy seems happy
and displeasure • Likes to look at self in a mirror
• Begins to say consonant
sounds (jabbering with
m, b )
• Understands no • May be afraid of strangers • Watches the path of something
• Makes a lot of different • May be clingy with as it falls
sounds like mamamama familiar adults • Looks for things he sees you hide
and bababababa • Has favorite toys • Plays peek-a-boo
• Copies sounds and gestures • Looks where you point
of others • Responds to own name
• Uses fingers to point at things
(continued)
56 Section 4

TABLE 4-7 (CONTINUED) . TABL

DEVELOPMENT OF FUNCTIONAL SKILLS/ABILITIES FROM BIRTH TO 6 YEARS BIRT
GROSS MOTOR FINE MOTOR ORAL MOTOR
AND FEEDING
1 yr • Gets to a sitting position • Brushes hair • Drinks from a
without help • Bangs 2 things together cup
• Pulls up to stand, walks holding on to • Explores things in different ways,
furniture (cruising) like shaking, banging, throwing
• May take a few steps without • Pokes with index (pointer) finger
holding on • Puts things in a container, takes
• May stand alone things out of a container
• Begins to walk with support; wide- • Uses pincer grasp
based gait

18 mos • Walks alone • Can help undress herself • Drinks from a

• May walk up steps and run cup
• Pulls toys while walking • Eats with a
spoon
 Overview of Human Growth and Development for Pediatric Therapists 57

LE 4-7 TABLE 4-7 (CONTINUED)

TH D DEVELOPMENT OF FUNCTIONAL SKILLS/ABILITIES FROM BIRTH TO 6 YEARS
ORAL MOTOR AND SOCIAL AND EMOTIONAL COGNITIVE
COMMUNICATION
• Responds to simple • Is shy or nervous with strangers • Finds hidden
spoken requests • Cries when mom or dad leaves things easily
• Uses simple gestures, like shaking • Has favorite things and people • Looks at the right
head no or waving bye-bye • Shows fear in some situations picture or thing
• Makes sounds with changes in when it s named
• Hands you a book when he wants to
tone (sounds more like speech) hear a story • Copies gestures
• Says mama and dada and • Repeats sounds or actions • Lets things go
exclamations like uh-oh! for attention without help
• Tries to say words you say • Puts out arm or leg to help • Follows simple
• Says bye-bye with dressing directions like pick
up the toy
• Plays games such as peek-a-boo and
pat-a-cake • Gestures by waving
or shaking head
• Says several single words • Likes to hand things to others • Knows what ordinary
• Says and shakes head no as he plays things are for (eg,
• Points to show someone what • May have temper tantrums telephone, brush,
he wants • May be afraid of strangers spoon)
• Shows affection to familiar people • Points to get the
attention of others
• Plays simple pretend, such as
feeding a doll • Shows interest in a
doll or stuffed
• May cling to caregivers in
animal by
new situations
pretending to feed
• Points to show others something
• Points to one
interesting
body part
• Explores alone but with parent
• Scribbles on his own
close by
• Can follow 1-step
verbal commands
without any gestures
(eg, sits when you
say sit down )
(continued)
58 Section 4

TABLE 4-7 (CONTINUED) . TABL

DEVELOPMENT OF FUNCTIONAL SKILLS/ABILITIES FROM BIRTH TO 6 YEARS BIRT
GROSS MOTOR FINE MOTOR ORAL MOTOR AND
FEEDING
2 yrs • Stands on tiptoe • Makes or copies straight lines • Refined spoon
• Kicks a ball and circles feeding: holds spoon
• Begins to run with radial grasp
• Climbs onto and down from • Finger feeds
furniture without help appropriate foods
• Walks up and down stairs • Licks upper lip
holding on with tongue
• Throws ball overhand • 2½ yrs: eats with a
fork by holding
it in fist
• Drinks from a
plastic straw

3 yrs • Climbs well • Dresses and undresses self • Stabs with a fork and
• Runs easily • Works toys with buttons, levers, uses fork for solids
• Pedals a tricycle (3-wheel bike) and moving parts • Serves self at table
• Walks up and down stairs, one • Copies a circle with pencil
foot on each step or crayon
• Builds towers of more than
6 blocks
• Screws and unscrews jar lids or
turns door handle
 Overview of Human Growth and Development for Pediatric Therapists 59

LE 4-7 TABLE 4-7 (CONTINUED)

TH D DEVELOPMENT OF FUNCTIONAL SKILLS/ABILITIES FROM BIRTH TO 6 YEARS
ORAL MOTOR AND SOCIAL AND EMOTIONAL COGNITIVE
COMMUNICATION
• Points to things or pictures • Early childhood: autonomy vs shame • Finds things even when
when they are named • Copies others, especially adults and hidden under 2 or 3
• Knows names of familiar older children covers
people and body parts • Gets excited when with other children • Begins to sort shapes
• Says sentences with 2 to • Shows more and more independence and colors
4 words • Shows defiant behavior (doing what • Completes sentences
• Follows simple instructions he has been told not to) and rhymes in
• Repeats words overheard in familiar books
• Plays mainly beside other children but
conversation is beginning to include other children, • Plays simple make-
• Points to things in a book such as in chase games believe games
• Builds towers of 4 or
more blocks
• Might use one hand
more than the other
• Follows 2-step
instructions such as, pick
up your shoes and put
them in the closet
• Names items in a picture
book, such as a cat, bird,
or dog
• Follows instructions with 2 or • Copies adults and friends • Begins to use symbols to
3 steps • Shows affection and concern represent objects
• Can name most familiar things for friends • Plays make-believe
• Understands in, on, • Takes turns with dolls, animals, and
and under • Understands the idea of mine and people
• Says first name, age, and sex his or hers • Understands what
• Names a friend • Shows a wide range of emotions two means
• Says I, me, we, and you • Separates easily from Mom and Dad • Turns book pages one at
and some plurals (eg, a time
• May get upset with changes
cats, dogs) in routine • Does puzzles with 3 or
• Intelligible speech 4 pieces
• Converses using 2 to 3 • Is oriented to the present
sentences • Has an egocentric
perspective
(continued)
60 Section 4

TABLE 4-7 (CONTINUED) . TABL

DEVELOPMENT OF FUNCTIONAL SKILLS/ABILITIES FROM BIRTH TO 6 YEARS BIRT
GROSS MOTOR FINE MOTOR ORAL MOTOR AND
FEEDING
4 yrs • Hops and stands on one foot up • Draws a person with 2 to 4 • Pours, cuts with
to 2 seconds body parts supervision, and
• Catches a bounced ball most of • Uses scissors mashes own food
the time • Starts to copy some capital
• Gallops letters

5 yrs • Stands on one foot for 10 • Can use the toilet on her own • Uses a fork and
seconds or longer • Can draw a person with at least spoon and
• Hops; may be able to skip 6 body parts sometimes a
• Can do a somersault • Can print some letters or table knife
• Swings and climbs numbers • Cuts and spreads
• Copies a triangle and other with knife
geometric shapes

families and caregivers about typical growth and develop-

ment, encouraging them to be alert to possible delays.
DEVELOPMENTAL RED FLAGS
Ideally, parents, caretakers, and professionals should observe
children in spontaneous play to observe preferred activities As an interprofessional team, therapists should recognize
and strategies for movement. Parents’ reports on the child’s typical development and make referrals to others when
activities at home tend to be accurate and can help identify delays in one or more areas are suspected. Red flags that
areas of strength and areas of concern. warrant close attention include the following:
As the child matures and goes through puberty, pediatric • Birth history risk factors: Prematurity, difficult delivery,
therapists need to gauge their interactions and interventions congenital conditions
to best match each individual child’s skills, including social • Medical history risk factors: Genetic and congenital
skills. Table 4-8 illustrates the range of functional skills that conditions
adolescents achieve as they mature into adulthood. • Family history risk factors: Genetic conditions, familial
risk factors
• Environmental factors: Diet, home environment (eg,
allergens, pets, smoke), lack of stimulation
 Overview of Human Growth and Development for Pediatric Therapists 61

LE 4-7 TABLE 4-7 (CONTINUED)

TH D DEVELOPMENT OF FUNCTIONAL SKILLS/ABILITIES FROM BIRTH TO 6 YEARS
ORAL MOTOR AND SOCIAL AND EMOTIONAL COGNITIVE
COMMUNICATION
• Knows some basic rules of • 4 to 5 yrs: Initiative vs guilt • Names some colors and
grammar, such as correctly • Enjoys doing new things some numbers
using he and she • Plays Mom and Dad • Understands the
• Sings a song or says a poem • Is more creative with make-believe idea of counting
from memory such as The Itsy • Starts to
• Would rather play with other children
Bitsy Spider or The Wheels understand time
than by herself
on the Bus • Remembers parts
• Cooperates with other children
• Tells stories of a story
• Often can t tell what s real and what s
• Can say first and last names • Understands the idea of
make-believe
• Language is well established same and different
• Talks about what she likes and what
she is interested in • Names 4 colors
• Plays board or
card games
• Tells you what he thinks
is going to happen next
in a book
• Speaks very clearly • Wants to please and be like friends • Counts 10 or
• Tells a simple story using full • More likely to agree with rules more things
sentences • Likes to sing, dance, and act • Knows about things
• Uses future tense (eg, • Shows concern and sympathy used every day, like
Grandma will be here ) for others money and food
• Says name and address • Is aware of gender
• Can tell what s real vs make-believe
• Shows more independence but adult
supervision is still needed
• Is sometimes demanding vs
cooperative

• Poor quality of movements: Lack of movement; trem- motor planning ability, crossing midline, interaction
ors; difficulty alternating movements; poorly coordi- with other children, use of receptive and expressive
nated movement; problems with strength, endurance, language
and power The environment for healthy growth and development
• Persistent asymmetry observed in relation to move- is a critical consideration. Last year, 3.6 million cases of
ments, postures, responses to developmental reflexes, child abuse and neglect were reported to state and local
and head positioning agencies in the United States, involving 6.6 million children
• Sensory disturbances: Lack of response or hypersensi- (reports can include multiple children).23-25 The United
tivity in one or more sensory modalities (ie, auditory, States has one of the worst records among industrialized
olfactory, gustatory, tactile, visual, and movement) nations, losing more than 4 children on average every day
to child abuse and neglect. Children who experience child
• Delays in preacademic skills: Eye contact, attention to
abuse and neglect are approximately 9 times more likely to
task, compliance, ability to follow directions, memory,
become involved in criminal activity.25,26 It is the second
imitation skills, copy skills, bilateral coordination, most common cause of deaths, second only to accidents.25
62 Section 4

TABLE 4-8 . TABL

DEVELOPMENT OF FUNCTIONS FROM 6 YEARS TO ADOLESCENCE BIRT
GROSS MOTOR FINE MOTOR ORAL MOTOR AND
FEEDING
6 to 9 yrs • 6 years: Refines skills for postural • 6 years: Has adult feeding skills • Has adult
control and mobility • 7 years: Handwriting is much oromotor skills
• Has a narrow base of support more legible
with arm swing • 8 years: Clearly prints all the
• 7 years: Is able to move more letters and numbers
gracefully and quickly • 9 years: Has adult level fine
• Enjoys team sports that motor coordination
incorporate intermittent running
and require a moderate level of
coordination
• 8 years: Plays ball (kicking and
throwing); can skillfully climb
• 9 years: Has adult-level skills
10 to • May appear clumsy secondary • Adult abilities • Adult abilities
18 yrs to a growth spurt (especially
feet and hands that grow before
long bones)
• With adaptation to growth spurt
motor performance is perfected:
increased motor control,
endurance, speed, reaction time,
coordination, balance
Over 18 yrs • Optimal speed and endurance • Optimal speed and accuracy • Optimal speed
• Power grasp and accuracy

People causing child abuse and neglect include natural commonly used to describe the development of communica-
parents, adoptive or foster parents, babysitters, siblings, and tion and language.
others (teachers, relatives, other adults).25 Working closely Similarly, occupational and physical therapists use terms
with families, therapists need to be alert to the possible risk commonly used in pediatric care. Table 4-11 lists terms that
of child abuse and neglect. Child abuse is the nonaccidental are helpful for describing the sensorimotor development of
injury of a child, and child neglect is the failure to provide the a child.
necessities of life for a child (eg, medical care, nourishment, The terminology used to describe cognitive and intel-
appropriate clothing, supervision, and adequate housing). lectual development in early childhood is most commonly
Pediatric therapists are legally responsible to report suspect- used in educational settings because physical therapists,
ed child abuse or neglect; however, it is important to make occupational therapists, and speech-language pathologists
the distinction between willful neglect and impoverishment. all strive to improve a child’s ability to learn and function as
Signs of possible abuse or neglect are listed in Table 4-9. If independently as possible. This independence relies upon a
a professional suspects a child is in immediate danger, he child’s ability to process information and use it in an adap-
should contact law enforcement as soon as possible. tive manner for problem solving in the real world. The key
Finally, it is important to recognize and understand terms that all professionals should recognize are listed in
terminology commonly used by fellow therapists for inter- Table 4-12.
professional discussions about a child’s growth, func- When using professional terminology with others, jargon
tional skills, and therapeutic needs. Table 4-10 lists terms should be avoided or explained, as needed. For example,
parents may need to understand the cognitive and motor
 Overview of Human Growth and Development for Pediatric Therapists 63

LE 4-7 TABLE 4-8

TH D DEVELOPMENT OF FUNCTIONS FROM 6 YEARS TO ADOLESCENCE
ORAL MOTOR AND SOCIAL AND EMOTIONAL COGNITIVE
COMMUNICATION
• Industry vs inferiority • 7 years: Selects toys and activities • Developing ability to
based on desire to interact with peers think abstractly
• 9 years: Values competition • Starts making rational
judgments about
concrete or observable
phenomena

• Develops adult vocabulary • Identity vs role confusion • Capable of hypothetical

(contingent upon education) and deductive reasoning
• Able to consider many
possibilities from several
perspectives

• Optimal skill • Young adulthood: Intimacy vs • Optimal speed and

isolation endurance

abilities of their child to buy appropriate toys. In addi- common foundations described in prior sections, Section 5
tion to discussing their child’s developmental abilities and will discuss interprofessional management care by pediatric
therapeutic activities, therapists can provide evidence-based, therapists.
family-friendly websites featuring developmental milestones
and play activities. See Appendix B for a list of websites fea-
turing helpful resources for professionals and families. INTERPROFESSIONAL ACTIVITY
Performing Developmental Reflex Testing
SUMMARY
This learning experience involves working as a team with
Sharing a similar knowledge of typical growth and devel- a child under 1 year.
opment provides a foundation for interprofessional collabo- 1. As a team of pediatric therapists, perform develop-
ration and appreciation of expertise when caring for children mental reflex testing on an infant.
and educating their caretakers. Furthermore, it sets the stage 2. First, interview the infant’s caretaker to assess possible
for interprofessional goals for learning and healthy develop- maternal, congenital, medical, or birth-related risk
ment for children and their families. It also allows therapists factors.
to recognize typical patterns of growth and development 3. Observe the child’s spontaneous behaviors.
vs those that warrant closer examination. Based upon the
64 Section 4

TABLE 4-9
RED FLAGS FOR CHILD ABUSE AND NEGLECT
TYPE OF PHYSICAL SIGNS BEHAVIORAL SIGNS CAREGIVER SIGNS
ABUSE
Physical Look for age-inappropriate Signs of physical abuse may be Physically abusive caregivers may
injuries, injuries that subtle. The child may be fearful, display anger management issues
appear to have a pattern shy away from touch, or appear and excessive need for control.
such as marks from a hand to be afraid to go home. A Their explanation of the injury
or belt, or a pattern of child s clothing may be might not ring true or may be
severe injuries. inappropriate for the weather, different from an older child s
such as heavy, long-sleeved description of the injury.
pants and shirts on hot days.
Emotional Because emotional child Is the child excessively shy, Does a caregiver seem unusually
abuse does not leave fearful, or afraid of doing harsh and critical of a child,
concrete marks, the something wrong? Behavioral belittling and shaming him in front
effects may be harder to extremes may also be a clue. A of others? Has the caregiver shown
detect. Look at the child s child may be constantly anger or issues with control in
behavior. trying to parent other children, other areas? A caregiver may also
for example, or, conversely, seem strangely unconcerned with
exhibit antisocial behavior such a child s welfare or performance.
as uncontrolled aggression. Keep in mind that there might
Look for age-inappropriate not be immediate caregiver signs.
behaviors as well, such as an Tragically, many emotionally
older child exhibiting behaviors abusive caregivers can present
more commonly found in a kind face to the outside world,
younger children. making the abuse of the child all
the more confusing and scary.

(continued)

4. Take turns performing the developmental reflexes, 2. Discuss the changes in growth and skill development
selecting those that best match your area of expertise. across domains that may impact a team’s focus as the
5. As a team, document the infant’s responses to each child ages from birth through adolescence.
stimulus. 3. Collaborate as a team to do the following:
6. Discuss the infant’s responses and how they reflect the a. Develop questions to ask the child, family, and
child’s overall growth and development. other shareholders about their needs and concerns.
7. Discuss the infant’s physical, mental, and psycho- b. Determine the roles and responsibilities interact-
social development in terms of developmental mile- ing with shareholders for your team meeting about
stones observed while testing the child. issues considering a child at 11 years (current age)
and following her growth spurt.
Discussing the Impact of Growth and c. Develop a team plan to discuss recommendations
Development on a Child for assistive technology when the child is 11 vs 18
years.
1. As a team, review the following case of the child with
spastic cerebral palsy.
 Overview of Human Growth and Development for Pediatric Therapists 65

TABLE 4-9 (CONTINUED)

RED FLAGS FOR CHILD ABUSE AND NEGLECT
TYPE OF PHYSICAL SIGNS BEHAVIORAL SIGNS CAREGIVER SIGNS
ABUSE
Sexual A child may have trouble Does the child display The caregiver may seem to be
sitting or standing or have knowledge or interest in sexual unusually controlling and
stained, bloody, or torn acts inappropriate to her age, protective of the child, limiting
underclothes. Swelling, or even seductive behavior? contact with other children and
bruises, or bleeding in the A child might appear to avoid adults. Again, as with other types
genital area is a red flag. A another person or display of abuse, sometimes the caregiver
sexually transmitted disease unusual behavior, either being does not give outward signs of
or pregnancy, especially very aggressive or very passive. concern. This does not mean the
under 14 years, is a strong Older children might resort to child is lying or exaggerating.
cause for concern. destructive behaviors to take
away the pain, such as alcohol
or drug abuse, self-mutilation, or
suicide attempts.
Neglect A child may consistently Does the child seem to be Does the caregiver have problems
be dressed inappropriately unsupervised? Schoolchildren with drugs or alcohol? Most of us
for the weather or have may be frequently late or tardy. have a little clutter in the home,
ill-fitting, dirty clothes The child might show but is the caregiver s home filthy
and shoes. He might have troublesome, disruptive and unsanitary? Is there adequate
consistently bad hygiene, behavior or be withdrawn and food in the house? A caregiver
appearing very dirty, passive. might also show reckless disregard
having matted and for the child s safety, letting older
unwashed hair, or having children play unsupervised or
noticeable body odor. leaving a baby unattended. A
Another warning sign is caregiver might refuse or delay
untreated illnesses and necessary health care for the child.
physical injuries.

Although her cognition is normal, her speech is severely dys-

arthric, making her communication a concern. She is unable
to assume sitting or standing and cannot maintain sitting
Case 4-1: An 11-year-old girl with spastic without support. Her mother or aide pushes her around in
a manual wheelchair, a chair she has outgrown. Mary cur-
cerebral palsy rently has a normal body mass index as she approaches her
Mary is an 11-year-old with spastic cerebral palsy present- adolescent growth spurt. She likes to read and talk to her
ing with intermittent hypertonicity of all extremities and friends on the phone. She will be going to a new school and
hypotonicity of her head, neck, and trunk. She has obligato- needs adaptive equipment to function in the school setting.
ry tonic reflexes (R>L) and poor gross motor control. Mary Her mother would like recommendations for therapeutic
has fair fine motor control when she is therapeutically posi- positioning to prevent deformities during her anticipated
tioned for postural support. When positioned properly, she growth spurt.
is able to reach and touch large targets with some accuracy.
66 Section 4

TABLE 4-10
COMMUNICATION TERMINOLOGY
TERM DEFINITION
Communication Ability to make information understood by others; ability to
exchange messages
Language A code in which arbitrary symbols stand for real things, ideas, and events

Receptive language Decoding aspect of communication; receptive language precedes

expressive language in both development and complexity
Expressive language Encoding of communication
Articulation Sensorimotor process or producing the language code
Respiration Act of breathing; inhaling and exhaling (a fundamental process of life)
Phonation Utterance of sounds by means of the vocal cords

Vocalization Any sound a person produces using his organs of speech

Articulation Distinct connected speech or enunciation
 Overview of Human Growth and Development for Pediatric Therapists 67

TABLE 4-11
TERMINOLOGY FOR PERCEPTION AND MOTOR CONTROL
TERM DEFINITION
Activity tolerance Sustaining a purposeful activity over time
Bilateral integration Interacting with both sides of the body in a coordination manner during activity
Body scheme Acquiring an internal awareness of the body and the relationship of body parts to each
other
Crossing the midline Moving the limbs and eyes across the sagittal plane of the body
Depth perception Determining the relative distance between objects, figures, or landmarks and the
observer
Endurance The ability to perform a skill over an increased time period
Figure ground Differentiating between foreground and background forms and objects
Fine motor coordination Using small muscle groups for controlled movements, particularly in object manipulation
Form constancy Recognizing forms and objects as the same in various environments, positions, and sizes
Graphesthesia Identifying letters or numbers drawn on the skin
Gross motor coordination Using the large muscle groups for controlled movement
Kinesthesia Identifying the excursion and direction of joint movement
Laterality Using a preferred unilateral body part for activities requiring a high level of skill
Left-right discrimination Differentiating on side of the body from the other
Motor control Ability to activate and coordinate the muscles and limbs involved in the performance of a
motor skill
Motor learning Process of acquiring a skill by which the learner, through practice and assimilation, refines
and makes automatic the desired movement.
Oral-motor coordination Coordinating oropharyngeal musculature for controlled movements
Perception The process of interpreting or giving meaning to an experience
Position in space Determining the spatial relationships of figures and objects to self or other forms and
objects
Power Ability to use strength in a short time frame, resulting in greater force
Praxis Conceiving and planning a new motor act in response to an environmental command
Spatial orientation Ability to maintain the body orientation and/or posture in relation to the surrounding
environment (physical space) at rest and during motion
Strength Ability to move a joint actively
Stereognosis Identifying objects through the sense of touch
Topographical orientation Determining the location of objects and settings and the route to the location
Visual closure Identifying forms or objects from incomplete presentations
Visual motor integration Coordinating the interaction of visual information with body movement during activity
68 Section 4

TABLE 4-12
TERMINOLOGY ASSOCIATED WITH COGNITIVE AND
INTELLECTUAL DEVELOPMENT IN EARLY CHILDHOOD
TERM DEFINITION
Accommodation The establishment of a new schema or the modification of an old schema; this results
in a change in, reorganization of, or development of cognitive structures (schemata)
Adaptive behavior Behavior that fosters appropriate individual interaction with the environment
Assimilation The cognitive process by which the person integrates new perceptual matter or
stimulus events into existing schemata or patterns of behavior
Attention span The ability to focus on a task over time
Behavior The way in which an individual acts or performs
Behavior modification Giving reinforcement to specific behaviors to encourage or discourage the repetition
of those behaviors
Categorization The ability to identify similarities of and differences between environmental
information
Cognition The process or act of knowing; our reception of raw sensory information and our
transformation, elaboration, storage, recovery, and use of this information; the
operation of the mind process by which we become aware of thought and perception,
including all aspects of perceiving, thinking, and remembering; involves sensing,
perceiving, recognizing, conceiving, judging, reasoning, and imagining
Concept formation The ability to organize a variety of information to form thoughts and ideas
Conceptualization The action or process of forming a concept or idea of something
Conditioning The process whereby individuals, as a result of their experience, establish an association
or linkage between 2 events
Contingent behavior Actions that are dependent upon a specific stimulus
Dishabituation The discrimination between to similar stimuli that causes a response
Equilibration The result of balance between the processes of assimilation and accommodation;
when disequilibration occurs, it provides motivation for the individual to assimilate or
to accommodate further
(continued)
 Overview of Human Growth and Development for Pediatric Therapists 69

TABLE 4-12 (CONTINUED)

TERMINOLOGY ASSOCIATED WITH COGNITIVE AND
INTELLECTUAL DEVELOPMENT IN EARLY CHILDHOOD
TERM DEFINITION
Generalization of The ability to apply previously learned concepts and behaviors to similar situations
learning
Habituation Repeated presentation of a stimulus that causes reduced attention to the stimulus
Imitation Performing an activity after having a model of the activity
Intellectual The ability to mentally manipulate spatial relationships
operations in space
Level of arousal Demonstrating alertness and responsiveness to environmental stimuli
Memory The retention of information over time:
• Short-term: Recall information for brief periods of time (15 to 30 seconds)
• Long-term: Recall information for long periods of time
• Remote: Recall events from the distant past
• Recent: Recall events from immediate past
• Declarative memory: Memory of knowledge
• Procedural memory: Memory of how to do a task
Object permanence Recognition that objects have an independent existence

Orientation The ability to identify person, place, time, and situation

Problem solving The ability to recognize a problem, define a problem, identify alternative plans, select a
plan, organize steps in a plan, implement a plan, and evaluate the outcome
Recognition Ability to identify familiar faces, objects, and other previously presented materials
Schema A cognitive structure with specific kinds of situations in their environment
Schemata Plural of schema
Sequencing Place information, concepts, and actions in order
Spatial transformation A mapping function that establishes a spatial correspondence between all points in an
image and its counterpart
70 Section 4

16. Dieter JN, Field T, Hernandez-Reif M, Emory EK, Redzepi M. Stable

REFERENCES preterm infants gain more weight and sleep less after five days of mas-
sage. J Pediatr Psychol. 2003;28:403-411.
1. Ruffin N. Human growth and development—A matter of principles. 17. Lagercrantz H, Changeux JP. The emergence of human consciousness:
https://pubs.ext.vt.edu/350/350-053/350-053_pdf.pdf. Published From fetal to neonatal life. Pediatr Res. 2009;65:255-260.
2013. Accessed January 25, 2017. 18. Ferber SG, Feldman R, Makhoul IR. The development of maternal
2. Carter R, Aldridge S, Page M, Parker S. The Human Brain Book. New touch across the first year of life. Early Hum Dev. 2008;84:363-370.
York, NY: DK Publishing; 2009. 19. Chugani HT, Behen ME, Muzik O, Juhasz C, Nagy F, Chugani
3. Durston S, Casey BJ. What have we learned about cognitive develop- DC. Local brain functional activity following early deprivation:
ment from neuroimaging? Neuropsychologia. 2006;44:2149-2157. A study of post-institutionalized Romanian orphans. Neuroimage.
4. Holmboe K, Pasco Fearon RM, Csibra G. Freeze-frame: a new infant 2001;14:1290-1301.
inhibition task and its relation to frontal cortex tasks during infancy 20. MacLean K. The impact of institutionalization on child development.
and early childhood. J Exp Child Psychol. 2008;100:89-114. Dev Psychopathol. 2003;15:853-884.
5. Skaliora I. Experience-dependent plasticity in the developing brain. 21. Beckett C, Maughan B, Rutter M, et al. Do the effects of early
International Congress Series. 2002;1241:313-320. severe deprivation on cognition persist into early adolescence?
6. Kagan J, Herschkowitz N, Herschkowitz E. A Young Mind in a Findings from the English and Romanian adoptees study. Child Dev.
Growing Brain. Mahwah, NJ: Lawrence Erlbaum Associates; 2005. 2006;77:696-711.
7. Sinclair D, Dangerfield P. Human Growth After Birth. 6th ed. New 22. Kellman P J & Arterberry ME. The Cradle of Knowledge: Development
York, NY: Oxford University Press; 1998. of Perception in Infancy. Cambridge, MA: MIT Press; 1998.
8. Bogin B. Patterns of Human Growth. Cambridge, UK: Cambridge 23. Tamis-LeMonda CS, Bornstein MH, Baumwell L. Maternal respon-
University Press; 1999. siveness and children’s achievement of language milestones. Child Dev.
9. Partanen E, Kujala T, Näätänen R, Liitola A, Sambeth A, Huotilainen 2001;72(3):748-767.
M. Learning-induced neural plasticity of speech processing before birth. 24. US National Library of Medicine. Infant reflexes. United States
Proceedings of National Academy of Sciences. 2013;110(37):15145-15150. National Library of Medicine Web site. https://medlineplus.gov/ency/
10. Kisilevsky BS1, Hains SM, Lee K, et al. Effects of experience on fetal article/003292.htm. Published December 5, 2017. Accessed December
voice recognition. Psychol Sci. 2003;14(3):220-224. 8, 2017.
11. Moon C. Language experienced in utero affects vowel perception after 25. US Department of Health and Human Services, Administration for
birth: a two-country study. Acta Paediatrica. 2013;102(2):156-160. Children and Families. Child Maltreatment 2013. Administration for
12. Mennella JA, Beauchamp GK. Infants’ exploration of scented toys: Children and Families Web site. http://www.acf.hhs.gov/sites/default/
Effects of prior experiences. Chem Senses. 1998;23:11-17. files/cb/cm2013.pdf. Published January 15, 2015. Accessed March 2,
13. Rosenstein D, Oster H. Differential facial responses to four basic 2017.
tastes in newborns. Child Dev. 1988;59:1555-1566. 26. US Department of Health and Human Services, Children’s Bureau.
14. Mennella JA, Jagnow CP, Beauchamp GK. Prenatal and postnatal Child maltreatment. Administration for Children and Families
flavor learning by human infants. Pediatrics. 2001;107(6):E88. Web site http://www.acf.hhs.gov/programs/cb/research-data-technol-
15. Montagu A. Touching: The Human Significance of the Skin. New York, ogy/statistics-research/child-maltreatment. Published 2016. Accessed
NY: Columbia University Press; 1971. March 2, 2017.
Section 5
Interprofessional Management of
Pediatric Care
Catherine Rush Thompson, PT, PhD, MS and Grace McConnell, PhD, CCC-SLP

The workplace culture can impact the extent of interac-

OVERVIEW tions and communication between professionals, families,
referral sources, and those responsible for payment. Pediatric
This section provides an overview of the workplace cul- professionals need to be sensitive to the needs of families
ture and key competencies for the interprofessional manage- as well as the workplace culture when managing care; they
ment of care, including selecting appropriate tests and mea- should support a workplace culture that encourages lateral
sures, interpreting results, developing an interprofessional leadership (providing peer guidance and encouragement),
plan of care, and providing age-appropriate interventions openness to new ideas, clear communication, professionalism,
to optimize an individual’s inclusion in education, social and interprofessional competency. For example, the neonatal
activities, and work. intensive care unit (NICU) focuses on intensive medical
attention to stabilize a neonate’s physical health, so medi-
cal team members use specialized care and technology to
WORKPLACE CULTURE manage the newborn’s body systems and body functions.1
The NICU is a protective environment designed to address
When managing care, pediatric professionals need to the multiple threats to a newborn’s life while supporting the
be sensitive to their workplace’s character and personality, parents’ need to bond with their child. In programs offer-
also referred to as the workplace culture. Workplace culture ing early intervention, the focus is on family education, so
relates to the values, beliefs, behaviors, and interactions that parenting skills and play activities are highly valued.2 As the
can impact interprofessional collaboration. For example, child grows to school age, the focus shifts to the child’s par-
pediatric professionals typically share child- and family- ticipation in learning and social activities.2 Although each
centered approaches to care; however, each person brings a workplace culture varies, key interprofessional competencies
unique cultural and perspective to the workplace. Similarly, for effective management are consistent. Each team member
each workplace embraces values that impact policies, pro- should take the time to understand each workplace culture
cedures, and interprofessional behaviors (eg, for profit vs in terms of what is expected and what is needed for optimal
nonprofit settings). care. Similarly, pediatric therapists need to be especially

Thompson CR. Pediatric Therapy:

An Interprofessional Framework for Practice (pp 71-83).
- 71 - © 2018 SLACK Incorporated.
72 Section 5

aware of the home environments where they provide ser- that all can view. The agenda should describe details of what
vices, recognizing the intimacy and trust that is required to will be discussed, who is responsible for leading the discus-
open one’s home to others. sion, and the order of discussion. For example, if the goal of
the meeting is to plan an assessment of a child, a designated
team leader or case manager could create an agenda that lists
KEY INTERPROFESSIONAL relevant items for discussion. Table 5-1 illustrates an agenda
that would be shared with all meeting participants.
COMPETENCIES FOR EFFECTIVE The first agenda item is typically to review the minutes
from the previous meeting, ensuring that the information is
MANAGEMENT clear and accurate. If any errors exist, changes are made to
the prior minutes, then the minutes from the prior meeting
As described in Section 1, the key principles for interpro- are approved. This approval is noted under Action, providing
fessional practice include the following: a record of the previous meeting. During the meeting, the
1. Sharing common values and ethics for interprofes- subsequent item is then addressed, ideally within the allot-
sional practice; ted time. Notes of the discussion are written on the agenda
2. Using the knowledge of one’s own role and those of form to keep minutes or a record of the current meeting
other professions to appropriately assess and address and decisions made. Minutes can be written by a designated
the health care needs of the children and families recorder or secretary. Any decisions that require follow-up are
served; written under Action. Whereas the discussion can be written
3. Communicating with children, families, communi- without specifying who made specific comments, the Action
ties, and other health professionals in a responsive items need to be written so that someone is held accountable
and responsible manner that supports a collaborative for ensuring that each task is addressed and reported at the
team approach for the maintenance of health and the following meeting.
treatment of disease; and
4. Building relationships for effectively planning and
delivering customized care that is safe, timely, effi- PREPARATION FOR TEAM MEETINGS
cient, effective, and equitable.
Following these principles, caring professionals can more In preparation for discussion, team members could bring
effectively work as a team for case management. By defi- the tools they would recommend for the assessment, based
nition, teamwork includes “the interrelated set of specific upon prior review of information from the child’s medical
knowledge (cognitive competencies), skills (affective compe- and/or educational history and parental interview. Table
tencies), and attitudes (behavioral competencies) required for 5-2 provides a helpful list of questions to seek in medical
an interprofessional team to function as a unit.”3 Although records, ask of a caretaker, or seek from other sources prior
professionals value teamwork and interprofessional collabo- to conducting a comprehensive assessment of an infant or
ration, many experience barriers to these efforts. Reported preschool child.5
barriers include limited time for interactions, lack of recep- Interview responses offer the team members a preview of
tiveness to ideas shared, lack of adaptability to recommenda- the family’s concerns and the relative abilities of the child to
tions made, poor written communication skills (ie, lack of be examined. This type of preliminary information provides
clear information), poor verbal communication skills, poor a general focus for the team members, reducing the chance
listening skills, conflict(s) with coworkers, limited resources of redundancy and ensuring the best use of time during
(eg, guidelines, training, counseling for interpersonal reac- the assessment process for each team member. Then, team
tions), and lack of interprofessional training.3 According to members will be better acquainted to probe further into
one study, the majority of interprofessional communication areas of expertise and to explain their selection and rationale
problems resulted from misunderstandings, followed by for tests and measures suggested.
personality differences, lack of follow-through, and poor
compliance with rules and regulations.4 Coworkers reported
that they best managed interpersonal conflict through keep- TEST SELECTION
ing communication open, being patient/taking time, col-
laborating with others, and focusing on the problem rather Team discussions rely on active listening and relation-
than the individual.4 ship building for effective interprofessional collaboration. If
Teams can work together most effectively if they come the physical therapist, occupational therapist, and speech-
well prepared for focused discussion. The information need- language pathologist each administer separate assessments,
ed for each meeting should be clearly laid out in an agenda the total time for examination could take over 3 hours and
 Interprofessional Management of Pediatric Care 73

TABLE 5-1
AGENDA FOR TEAM MEETINGS
AGENDA
Date: February 26, 2017

Meeting Leader (can be rotated): Nancy Moore (Case Manager)

Team Members: Cary Jones (PT), Jennifer Dawson (OT), Emily Morrison (SLP)

Present: All Absent: None Excused: None

ITEM DISCUSSION ACTION

Approval of Minutes Discuss minutes from prior Approval of minutes with changes, if
meeting, if applicable. Make needed.
changes in minutes, as needed.
Discussion

PT Facilitator: Carrie J.
Time allotted: 5 min.
Discussion

OT Facilitator: Jennifer D.
Time allotted: 5 min.
Discussion

SLP Facilitator: Emily M.

Time allotted: 5 min.
Discussion

Selection of Assessments Facilitator: Nancy

Time allotted: 15 min.
Discussion

Reports Facilitator: Nancy

Time allotted: 10 min.
Discussion

Next Meeting Note the date, time, and place for

the next scheduled meeting.
Respectfully submitted by:____________________________
(Rotate the person submitting completed minutes. Copies of completed minutes need to be shared before
the next meeting.)
74 Section 5

TABLE 5-2
COMPREHENSIVE CHILD DEVELOPMENTAL AND OCCUPATIONAL HISTORY
Child s name:______________ Mother s name:______________ Occupation:______________

Child s birth date:______________ Father s name:______________ Occupation:______________

Child s age:______________ Today s date:______________

*Child s prematurity is adjusted on tests up to age 2.

PART I: Prenatal History̶Questions related to mother s pregnancies and this delivery

Have you been pregnant before? (Follow-up asking about previous pregnancies)

If you have been pregnant before, how many times?

Were there problems during other pregnancies? If so, please specify:

(eg, preeclampsia, ectopic pregnancy, complications with umbilical cord)

What was the length of this pregnancy?______________weeks (Full term pregnancy, 40 weeks;
premature, < 38 weeks)

Duration of labor for this child:______________ (Prolonged labor can increase risk for hypoxia)

Type of delivery: vaginal?____ C-section?____ Any complications? (eg, breech delivery, forceps)

Were there any maternal problems during this pregnancy? If so, please describe:

PART II: Child s Early History̶Questions about this child s early development
What was the condition of your child at birth? (eg, healthy, at risk, requiring neonatal intensive care)

What problems were evident at birth? (eg, Rh incompatibility = need for blood transfusion)

Were you aware of any problems before your child s birth?

What was your child s Apgar score at 1 minute? (8-10 is normal; 0-3 risk)

What was your child s Apgar score at 5 minutes? (0-3 risk)

What was your child s birth weight? (low birth weight < 1500 gm; track growth)

What was your child s height at birth? (see birth chart for normal vs abnormal)

BEHAVIORS

SLEEP

What were your child s sleep patterns after birth?

Where does your child sleep?

In what position(s) does your child sleep?

Has your child had any problems with sleep since birth?
(continued)
 Interprofessional Management of Pediatric Care 75

TABLE 5-2 (CONTINUED)

COMPREHENSIVE CHILD DEVELOPMENTAL AND OCCUPATIONAL HISTORY
NUTRITION AND DENTITION

What is your child s typical diet?

Does your child have any problems with feeding or eating habits?

Does your child have allergies and/or diet restrictions? (specify): (common allergies: milk, peanut
products, seafood)

Is your child teething now? (teething is often accompanied by drooling and continual crying)

ELIMINATION

Does your child have any problems with bowel or bladder (eg, constipation, diarrhea)

Is your child toilet trained? (typical age = 18 mos to 2 yrs)

Are there any problems related to your child s toileting? (eg, possible problems with sphincter control,
possible emotional problems)

PHYSICAL ACTIVITY

What is your child s favorite activity? (identifies reinforcers; eg, favorite toys/activities)

How does your child react to movement? (lack of movement suggests poor muscle tone)

MEDICAL HISTORY

Has your child been hospitalized since birth? (specify): (note specifics: date, location, surgery, physician,
outcomes)

Does your child have a history of ear infections? (specify): (follow-up with screening for hearing and
language development)

Does your child have any other medical problems or had medical tests to rule out possible medical
problems? (if medical history, request release of information for complete medical records)

DEVELOPMENTAL MILESTONES

Check milestones that have been met:

□ Maintains eye contact with parent (normally by 2-3 mos; red flag for autism)
□ Holds head upright while supported (2 mos)
□ Sits alone (6-7 mos)
□ Crawls on all fours (8-9 mos)
□ Babbles (normally before 9 mos; red flag for autism)
□ Gestures: waving, pointing, and showing (normally before 9 mos; red flag for autism)
□ Pulls to stand through half-kneel (10-11 mos)
□ Walks alone (12 mos)
□ Picks up objects from floor (13-18 mos)
□ Creeps upstairs (13-18 mos)
(continued)
76 Section 5

TABLE 5-2 (CONTINUED)

COMPREHENSIVE CHILD DEVELOPMENTAL AND OCCUPATIONAL HISTORY
□ Creeps downstairs (18-24 mos)
□ Runs (18-24 mos)
□ Catches a large ball (4-5 yrs)
□ Uses single words (13-18 mos)
□ Understands and follows simple commands (13-18 mos)
□ Shakes head no (13-18 mos)
□ Points to body parts
□ Uses 2-word sentences (18-24 mos)
□ Uses 3- to 4-word sentences (24-36 mos)
□ Asks questions (24-26 mos)
□ Drinks from a cup (10-12 mos)
□ Dresses self (3 yrs)
□ Uses a spoon (10-12 mos)
□ Uses a knife (3-5 yrs)
□ Uses markers or crayons (scribbles; 18-24 mos)
□ Kicks ball (24-36 mos)
□ Tells a short story (1 to 2 events) (27 mos and older)
□ Retells a short story (30-36 mos)

PART III: Present Status̶Current care, concerns, and management

1. Parent(s) current concerns: (eg, vision, hearing, antigravity movement, behavior [irritable, lethargic])
2. Current medications:
3. Current illnesses and management:

HOME ‒ FAMILY SUPPORT

Family support:

Names and ages of siblings:

Are the other siblings in good general health? If not, please describe:

4. Interaction with other children (siblings/peers):

5. Attendance at day care, playgroups, other (specify):
6. Physician s name:
7. Physician s address:
8. Physician s phone:
9. Names of other specialists working with your child:
10. What is the family s history since the birth of this child (note moves, changes, significant traumas, or
other problems)
11. Other comments:

______________________________________ _____________________
Team Members Date
 Interprofessional Management of Pediatric Care 77

the child’s performance would likely deteriorate over time. practice settings. For the younger child, an informal envi-
The interprofessional team should talk with those staff who ronmental assessment may address activities in the home,
know the child and family to prioritize tests and measures, social activities such as athletics and social groups, and
determine the possibility of testing over several sessions, school functioning. For the adolescent with special needs,
consider the urgency for test results, and ensure that resourc- the environmental assessment may also include a job site,
es are available for test administration. Other considerations social activities with peers (such as church events and shop-
could include the following: ping), and ongoing therapies at a local rehabilitation facility.
• Variability in performance based upon the time of day The individual’s functioning may vary across sites because
(eg, nap and meal times) the demands upon a child are quite different when in the
• Limited language skills of a younger child/the primary classroom, in the cafeteria, in music class, and so on. With
language of the child so much at stake, a complete picture of the child’s strengths
and weaknesses/concerns needs to be developed.
• Family’s culture and ethnicity
Tests and measures, sometimes referred to as assessments,
• Child’s endurance and risk for fatigue are designed to help professionals gather relevant knowledge
• Child’s separation anxiety (after 9 months) about the child, family, and various environments for inte-
• Child’s attention span/distractibility grated clinical decision making. Assessment is an ongoing,
• Child’s comfort dynamic process, with no, one protocol or test meeting the
• Child’s compliance needs of every child, regardless of age. The interprofessional
team needs to bring sensitivity for individual needs, flexibil-
• Family’s transportation needs ity, clinical judgment, and research support into the design
• Privacy and who should be present during testing of an assessment strategy. For a more complete picture of
• Most recent concerns, issues, and complaints by the the child’s level of performance, potential for growth, and
child, family, and caretakers personal needs, many measures and perspectives need to be
• Primary desires/needs of the family and child, includ- brought in for consideration. An individual’s needs for tar-
ing language preferences and cultural preferences that get performance are impacted by social and cultural norms.
impact service delivery Therefore, no standard set of tests and measures will work
for every individual. As a result, the interprofessional team
• Child’s current health status (eg, changes in medical
needs to follow a collaborative system of selecting appropri-
diagnoses, recent clinical tests, current anthropometrics)
ate assessments for each individual client.
• Child’s current medications As mentioned earlier, a thorough case history, including
• Planned/upcoming medical interventions for the child past and present concerns, can lay the basis for understand-
• Performance limitations as related to the individual ing relevant problems. An understanding of the family and
disease, disorder, and/or condition its social patterns help contribute to understanding their
This information should be reviewed in light of criteria for priorities, routines, and needs. The interprofessional team
selecting specific tests and measures during assessment, as can interview both the individual (if the child is able to
outlined in Table 5-2. Scheduling a series of tests and mea- respond) and others who interact regularly with that child.
sures at the child’s optimal time of day may yield the best Team members should also perform their own observations
results. of the individual in multiple settings. This information is
The team is charged with determining the child’s and crucial in describing practical levels of performance, as well
family’s needs and concerns, and the focus of intervention as identifying projected needs across environments.
will be to meet the needs of the child and the family while Interprofessional team members may also choose to
empowering them to manage health concerns. Additionally, administer a variety of standardized assessments to supple-
it is important to address any issues raised by referral sources. ment their interviews and observations. Standardized assess-
Before quality intervention and instruction can be deliv- ments need to be sensitive and selective. Most importantly,
ered, appropriate assessments of a child’s current level of the child should be represented in the population used for
functioning must be completed. Moreover, assessments of the test interpretation of the standardized assessment. Table
a child’s potential for learning can aid in more accurately 5-3 describes key psychometric properties that can be used
determining prognosis, possible additional assessments, for selecting an appropriate standardized test.6
therapy goals, intervention strategies, potential length and Norm-referenced tests rely on comparisons of the child’s
trajectory of therapy, and benchmarks for completion of performance to the performance of other typical children
services. with similar demographics. Screenings are usually done with
Environmental assessments (both physical and psy- norm-referenced tests. These tests can compare children to
chosocial environments) should also be considered across others of comparable age to determine whether there is a
developmental delay in one or more areas of function. If the
78 Section 5

TABLE 5-3
SELECTING A STANDARDIZED TEST
Developmental testing is most accurate when using standardized tests with strong psychometric parameters.
Below are criteria that can be used to select an appropriate standardized test in pediatrics.
• Validity: The extent to which measurements are useful for making decisions relevant to a given purpose.
Validity refers to the appropriateness, truthfulness, authenticity, and effectiveness of the test. Does the test
measure what it was intended to measure?
º Domain validity: This type of validity refers to the relationship of this test to other tests measuring the
same domain or a similar construct.
º Construct validity: This type of validity refers to the hypothetic construct or domain you intend to
study. It defines what you intend to measure. The test content matches descriptors of the same
concept described in research studies.
º Face validity: The test makes sense to the person to whom it is administered. The individual accepts
the test.
º Content validity: The content of the test is narrowed to specific items or content that is essential for the
domain that is being measured.
º Concurrent validity: The results of this test concur with findings from other tests examining the same
construct at the same time on the same individual.
º Predictive validity: The test is able to predict future events or behaviors.
• Reliability: Will the test give the same results if used under the same circumstances?
º Interobserver reliability: Does changing observer change the test score?
º Decision-consistency reliability: Stability of decisions.
º Test-rest reliability: Stability of individual scores when the test is given by a different examiner.
º Intrarater reliability: This type of reliability refers to the consistency of test scores when the same
examiner gives the same test. It indicates the stability of the measure.
º Test-retest reliability: This type of reliability refers to the accuracy of the same test used in repeated
measures for the same construct.

child is delayed, a more thorough examination could include to learn.8,9 DA has also been shown to be a sensitive measure
criterion-referenced tests. Criterion-referenced tests assess a for children from culturally and linguistically diverse back-
child’s task performance in relation to specific task criteria. grounds.10 Assessments can be devised to reveal important
Although criterion-referenced tests are helpful, reports must aspects of learning, including the child’s (1) ease at learning
clearly state the limitations of the test results. Table 5-4 pro- a new skill, (2) ability to focus attention on a task, (3) ability
vides a helpful comparison of norm-referenced vs criterion- to complete a task, (4) ability to transfer skills to new tasks,
referenced tests.7 (5) persistence, (6) enthusiasm, (7) planning skills, and (8)
Often standardized assessments target discrete skills self-regulation.
that may not translate into the overall skills needed by the Dynamic assessments are generally developed using a
child to successfully function in the home, school, and test-teach-retest model, using graduated prompting to see
other social environments. Children from linguistically and how much support the child requires to learn a new skill.
culturally diverse groups benefit from alternate methods With this mediated learning experience (MLE), the exam-
of assessment. Even for children who are within the main- iner can judge how much effort the child and teacher must
stream culture, standardized assessments may reveal mainly expend for the child to learn a new task.11 If the child learns
what a child does not know and not necessarily what a child a new skill easily, possibly more exposure is needed, not nec-
knows or is capable of learning. Dynamic assessment (DA), essarily intervention. However, if intervention is indicated,
designed using Vigotsky’s model of cognitive development, the learning strategies and prompts that are most effective
can provide information about the child’s ability to respond when working with the child can be identified.10,11
to new learning experiences, revealing the child’s potential
 Interprofessional Management of Pediatric Care 79

TABLE 5-4
NORM-REFERENCED AND CRITERION-REFERENCED TESTS
NORM-REFERENCED CRITERION-REFERENCED
Purpose To examine individual To examine an individual performance in relation to a
performance in relation to a criterion or external standard. Used for evaluation and
representative group. Used for program planning. These tests help demonstrate the
diagnosis and placement. effectiveness of intervention.
Test construction Items developed from activities Items developed from task analysis related to an
hypothesized to test specific objective that can be accomplished through
skills or performances. intervention.
Administration Standardized administration. May or may not be standardized.
Scoring Based on standards relative to Based on absolute standards. There is no variability in
a group or normal distribution. scores because mastery of each skill is desired.
There may be variability in
scores with means and
standard deviations.
Psychometric Test should demonstrate Test should demonstrate reliability and validity
properties reliability and validity
Reference points Standards represent a range of Standards are established by the consensus of experts.
or standards performances with an average
score used as a standard
for comparison.
Comparisons The individual s performance is The individual s performance is compared with a fixed
made or evalua- compared with the standard. The individual is subsequently compared with
tion standard group norm. herself.
Relationship to May or may not relate to Is specific to interventional content. Has a high
intervention intervention. Is generally not overlap with interventional objectives. Identifies levels of
very sensitive to impact of mastery for a specific performance and guides level of
intervention. Does not instruction.
necessarily measure the mastery
of performance.
Variability Variability is expected as scores Variability is not expected; mastery of a skill is expected.
should represent a normal Narrowly samples a specific domain.
distribution curve.
Reporting results Interpretation is based upon Interpretation is based upon mastery of skills. Reports
comparison with a specific relate specific and detailed information about the
population. Results provide a individual s performance.
summary of overall
performance in a domain.
80 Section 5

Team members can help caretakers appreciate learned

CONDUCTING INTERPROFESSIONAL helplessness so they understand why therapists require chil-
ASSESSMENTS dren to perform tasks with no prompting.12 Caretakers
must realize that children learn very quickly that someone
After prioritizing the tests and measures the team will else will perform a task for them if they hesitate or do not
administer, they must consider a strategy to get the child’s perform the task correctly on the first trial, leading children
performance in the most economical fashion. Ideally, the to act helpless when they may be capable of performing a
team should avoid tests that might cause discomfort or task. Allowing trial and error as much as possible enables
distress until the end of the testing session (eg, pain sensa- children with impairments the rare opportunity of strug-
tion). Also, for the sake of efficiency, team members should gling through the physical and mental challenges of new
work cooperatively before the actual assessment to identify activities. Team members may offer assistance in performing
appropriate resources to meet anticipated needs. Oftentimes, tasks (only as needed and allowed by the tests) by using (1)
families appreciate readily available educational, medical, verbal cues or gestures, (2) graded manual assistance (physi-
and financial resources that might be needed for the child’s cal prompts that are graded from minimal to maximum
optimal development and equipment needs. assistance), and (3) modeling to allow the child to imitate
The team should set up an optimal test environment certain skills.
before the child enters. The space should be comfortable Team members should be prepared for documenting the
(temperature), controlled for distracting sounds or activity, session, using appropriate forms and technology (eg, video-
and ready with equipment and markers for tests and mea- taping or recording) to best capture the child’s performance.
sures. With young children, all activities for testing need to Through collaborative efforts and using test batteries that
be prepared and within reach, but out of the child’s reach or incorporate multiple assessments, team members can aid in
eyesight. It is helpful to ask the parent or caretaker to bring data collection as needed.
the child’s favorite toys and to have age-appropriate popular Analyses of data in conjunction with the child’s history
toys on hand for use, if needed. and interviews of caretakers and others provide the essential
Interpersonal interactions are key to successful team- information for developing a plan of care. The plan of care
work. Recognizing that the family member or caretaker may include (1) retaining the child/family for intervention,
is a part of the team, all professionals should introduce (2) consulting with and/or referring to other health care
themselves to the parent and the child, explaining the pur- practitioners to address issues out of the team’s scope of
pose of selected tests and measures. The physical therapist, practice or expertise, (3) addressing risk factors and risk-
occupational therapist, and speech-language pathologist reduction needs through consultation, and (4) recommend-
should also attempt talking to the child to gain as much ing activities and resources to promote the child’s needs for
information as possible directly from the child, including healthy growth and development.
capabilities and interests.
Observations of spontaneous behaviors give a window of
insight into the child’s natural behavior. The team members DEVELOPING INTERPROFESSIONAL
should ask the child to perform a specific task that is report-
edly something he or she can successfully perform. While PLANS OF CARE
interacting with the child, the team should take note of the
child’s responsiveness, changes in posture, fine and gross When developing a child’s plan of care, the team must
motor movements (including preferential use of extremities), consider legislative guidelines that dictate what the team is
attempts to communicate verbally and nonverbally, general legally able to offer children and their families. Based upon
mood, level of energy, and general appearance. Many times, legal and financial considerations, schools typically provide
team members use observations and knowledge of neuro- different health care and educational resources than what
development to ascertain functional skills when children medical centers offer.
are unable to perform standardized or criterion-referenced
assessments. The School Environment
For younger children, it is often necessary to motivate In today’s schools, from pre-kindergarten through high
the child using a goal-directed task or game or an age- school, all students, regardless of any disabilities, are
appropriate toy. The team may incorporate toys into the included in the educational process. Federal laws, such as
testing situation as appropriate (eg, asking a 3-year-old child the Individuals with Disabilities Education Act,1 and state
to reach for a See ’n Say toy that is activated when the child laws, mandate the provision of services to student with spe-
successfully touches the toy). cial needs. To serve the needs of this population, a diverse
range of professionals are required. Collaboration lessens the
 Interprofessional Management of Pediatric Care 81

overlap of services and improves outcomes for the children motivational toys and games, and providing comprehensive
they serve. By professionals sharing assessment and inter- care.13 Goals are most easily measured with the use of the
vention responsibilities, more critical eyes can be brought SMART acronym: specific, measurable, achievable, realis-
to observe students’ performance in a multitude of envi- tic, and timely goals.14 Table 5-5 illustrates an outline for
ronments. With this interprofessional input, students have developing an interprofessional plan of care based upon the
the opportunity to have instruction, reinforcement, and ICF Model.
practice in their needed skills over a variety of environments
and with a variety of individuals. This coordinated effort
can result in quicker, more efficacious results and greater
generalization of skills due to the more consistent and more
PREVENTIVE CARE FOR HEALTHY
frequent reinforcement. GROWTH AND DEVELOPMENT ACROSS
The composition of the interprofessional team in school
depends upon the dynamic needs of the student. Some PRACTICE SETTINGS
representatives from different professions may interact more
during assessments but may only provide consultation Interprofessional teams must serve as a safety net in both
services or no interventions, depending on the student’s medical and educational settings where care may be com-
needs. The overarching mantra for team members must be partmentalized. Genetics or inherited characteristics play a
open and regular communication about the child’s level key role in an infant’s physical and psychological makeup;
of functioning and progress toward achieving educational however, physical activity and other environmental factors
goals. The provision of interprofessional collaboration in can nurture a child, greatly influencing her healthy growth
educational environments is discussed in greater detail in and proper development, increasing fitness, and emergent
Sections 8 and 9. wellness. Combinations of genetic and environmental fac-
tors, including stressors the family may be encountering,
The Medical Environment play key roles in these maturational processes. Certain
aspects of growth are more strongly influenced by genetic
Team-based care in the medical environment typically factors, including dental development, the sequence of bone
involves treating children with acute or chronic conditions. ossification, and sexual differentiation during puberty, but
Inpatient and outpatient medical care are both designed all are shaped by environmental factors. The interprofes-
to help families manage the health conditions that restrict sional team should offer health promotion education and
the child’s ability to live at home, attend school regularly, resources that help families deal with daily challenges, as
and/or engage in regular activities. Most pediatric hospi- well as stress the importance of healthy lifestyle choices (eg,
tals offer specialty clinics to address specific needs, such as sleep, nutrition, fitness, hydration, immunizations, stress
burn and trauma care, weight management, immunology, management) that can provide the most positive impact on
asthma, adolescent medicine, Down syndrome, wheelchair their children.
seating, orthotics, and abdominal pain.
Just as teams within a culture must be sensitive to the
many factors influencing the delivery of care within a set-
ting, so must professionals sensitively communicate between
SUMMARY
medical and school settings to ensure continuity of care Physical therapists, occupational therapists, and speech-
and collaborative management to best meet the child’s and language pathologists can work alongside others in medical,
family’s needs. Because the regulations governing care var- educational, and community settings in a collaborative
ies between settings, Section 10 will provide examples of effort to promote healthy growth and development of chil-
common health conditions and how they are managed in dren in their care. In the community, health care providers
medical settings. can provide screenings for children in daycares, schools,
and community centers. In the medical setting, pediatric
therapists can more carefully examine children with spe-
DEVELOPING AN cial needs, offering suggestions for individualized care that
promotes healing and reduces the risks of future injury or
INTERPROFESSIONAL PLAN OF CARE illness. All health professionals need to work with families
to help their children achieve functional goals and healthy
Pediatric therapists can use the International Classification bodies. Similarly, teachers and school-based professionals
of Functioning, Disability and Health (ICF) Model as can collaborate with pediatric therapists to identify chil-
one method for developing goals and intervention strate- dren at risk for developmental or learning disabilities that
gies, addressing equipment needs, considering appropriate can impact them throughout their lives. Through early
82 Section 5

TABLE 5-5
DEVELOPING A PLAN OF CARE BASED ON THE INTERNATIONAL CLASSIFICATION OF
FUNCTIONING, DISABILITY, AND HEALTH MODEL
PLAN OF CARE
Child s Name: Joey Age: 3 years Health Condition: Cerebral palsy, hypotonia

Team Members: Date:

ACTIVITY HYPOTHESES FOR ACTIVITY SMART GOALS, INTERVENTION

LIMITATIONS LIMITATIONS STRATEGIES
(ACTIVITIES, EQUIPMENT,
MOTIVATION GAMES OR TOYS)
• Nonverbal Body Structure/Body Function
• Poor postural control • Growth: low body mass index
• Dependent in all • Neuromuscular system: low muscle
mobility tone, sensory dysfunction, delayed
• Dependent in all developmental reflexes
self-care, including • Musculoskeletal system: decreased
feeding strength, range of motion, endur-
• Unable to sit for 2 ance, flexibility
sec • Cardiopulmonary system: short of air,
• Holds head for < 2 poor endurance
sec • Integumentary system: poor skin
• Unable to maintain integrity
attention to tasks • Other body systems: abdominal pain
from constipation
Environmental Factors
• To be determined
Personal Factors
• Poor motivation, fatigues easily
• ↑ fatigue
Participation
• Not socially engaged in activity with
others

detection, risk management, and collaborative teamwork, therapeutic play and leisure skills based upon dynamic
therapists can offer their expertise to enhance the well-being assessment, challenging children with activities that enhance
of children and their families. creativity and problem solving, and creating psychosocial
Each section of this manual goes into greater detail environments that are supportive of learning and inclusion
regarding how therapists can work collaboratively with in the community, pediatric therapists manage essential ele-
families, teachers, and others to provide a health safety ments of interprofessional care that can significantly impact
net for families. By promoting healthy lifestyles, offering a community’s well-being.
health education, engaging children and their families in
 Interprofessional Management of Pediatric Care 83

polydactyly, atresia of the choanae (blocked nasal breath-

INTERPROFESSIONAL ACTIVITY ing passages), a cleft palate, and sensorineural hearing loss
on both sides. She reportedly also has a minor atrial septal
Case Management defect. She is in the 10th percentile for height, weight, and
Use the following case study to discuss interprofessional head circumference. She crawls but is unable to pull to stand
management of care. or walk. You have no information from the family.
1. Use interprofessional collaboration to plan a child’s
assessment:
a. Identify agenda items to include in your preassess- REFERENCES
ment meeting.
1. Stanford Children’s Health. The neonatal intensive care unit (NICU).
b. Take turns facilitating discussion for each agenda Stanford Children’s Health Web site. http://www.stanfordchild-
item. rens.org/en/topic/default?id=the-neonatal-intensive-care-unit-nicu-
90-P02389. Accessed February 14, 2017.
c. Discuss factors the team should consider when
2. US Department of Education. Individuals with Disabilities Education
administering tests and measures. Act. US Department of Education Web site. https://www2.ed.gov/
d. Discuss factors impacting goal development for about/offices/list/osers/osep/osep-idea.html. Accessed February 14,
the child. 2017.
3. Salas E, Diaz Granados D, Weaver SJ, King H. Does team training
e. Ensure that information is documented on the work? Principles for health care. Acad Emerg Med. 2008;15:1002-1009.
agenda by a designated reporter. 4. Thompson CR. Perceptions of Interprofessional Collaboration in Special
f. Complete the meeting with action items listing at Education [research forum]. Missouri: Rockhurst University; 2017.
5. Thompson CR. Developmental history. In: Prevention Practice and
least one person responsible for follow-up of each
Health Promotion: A Health Care Professional’s Guide to Health,
item. Fitness, and Wellness. 2nd ed. Thorofare, NJ: SLACK Incorporated;
g. Approve minutes from your meeting (with chang- 2015:347-349.
es, if needed). 6. University of California at Davis. Reliability and validity. University
of California at Davis Web site. http://psc.dss.ucdavis.edu/sommerb/
2. As a team, discuss how you plan to share your assess- sommerdemo/intro/validity.htm. Accessed February 14, 2017.
ment results with various stakeholders, as appropriate: 7. Montgomery PC, Connolly BH. Norm-referenced and criterion-
a. Family referenced tests. Use in pediatrics and application to task analysis of
motor skill. Phys Ther. 1987;67(12):1873-1876.
b. Referral source 8. Vygotsky LS. Thought and Language. Cambridge, MA: MIT Press;
c. School 1986.
9. Peña E, Quinn R, Iglesias A. The application of dynamic methods
d. Physician
to language assessment: A nonbiased procedure. Journal of Special
Education. 1992;26:269-280.
10. Gutiérrez-Clellen VF, Peña E. Dynamic assessment of diverse chil-
dren: A tutorial. Lang Speech Hear Serv Sch. 2001;32:212-224.
11. American Speech-Language-Hearing Association. Position statement:
Social dialects. American Speech-Language-Hearing Association
Web site. http://www.asha.org/policy/PS1983-00115.htm. Accessed
February 14, 2017.
Case 5-1: An 18-month-old girl with 12. Tennen H, Eller SJ. Attributional components of learned helplessness
and facilitation. J Pers Soc Psychol. 1977;35:265-271.
CHARGE syndrome 13. World Health Organization. International Classification of
Functioning, Disability and Health (ICF). World Health Organization
Your team is asked to perform an assessment of a new Web site. http://www.who.int/classifications/icf/en/. Accessed
child who will be coming to your community-based private February 14, 2017.
practice next week. Jessie is an 18-month-old girl with hear- 14. Doran GT. There’s a S.M.A.R.T. way to write management’s goals and
ing, speech, visual (left eye coloboma), and motor problems objectives. Management Review. 1981;70:35.
15. Genetics Home Reference. CHARGE syndrome. Genetics Home
associated with her diagnosis of CHARGE syndrome.15 She Reference Web site. https://ghr.nlm.nih.gov/condition/charge-syn-
squints and has spontaneous nystagmus, facial asymmetry, drome. Published February 14, 2017.Accessed February 14, 2017.
Section 6
Interprofessional Care of
High-Risk Infants
Pamela Hart, PhD, CCC-SLP; Carol Koch, EdD, CCC-SLP; and
Catherine Rush Thompson, PT, PhD, MS

including ethical considerations, to address common prob-

OVERVIEW lems faced in working with families of high-risk infants, (8)
describe preventive care for mothers seeking to become preg-
This section provides an overview of the interprofessional nant in the future, and (9) discuss the process that facilitates
care of high-risk infants typically seen in the neonatal inten- the transition of the family with a high-risk infant to early
sive care unit (NICU). Information in this section addresses intervention.
foundational concepts for clinical practice in the NICU,
including characteristics of the high-risk neonate; risk fac-
tors that influence the infant’s growth and development; the
unique roles and responsibilities professionals who provide CRITICAL PERIODS IN PRENATAL
care to high-risk infants and their families; terminology
related to the care of high-risk infants; the family systems
GROWTH AND DEVELOPMENT
theory approach and how it relates to the management of
Infants may be born prematurely, full-term, or post-
care for high-risk infants; and the important ethical con-
term, depending upon genetic and environmental factors.
siderations that team members must face when providing
Although clinicians have little impact on genetic factors,
care to high-risk infants. Upon completion of this unit, the
they can influence environmental factors. What could
learner will be able to (1) discuss critical periods in prenatal
these environmental factors include? In the case of the fetus,
growth and development, (2) describe risk factors associated
environmental factors could include the mother’s nutrition
with the high-risk infant, including prematurity and low
and alcohol intake, which can potentially impact prenatal
birth weight, (3) distinguish the roles and responsibilities
growth and development in utero. To best understand the
of professionals working with high-risk infants, (4) describe
differences between these populations and the impact of
tests and measures commonly used for pregnant mothers
possible environmental factors, therapists should be familiar
and their newborns, (5) discuss interprofessional collabora-
with prenatal growth and development, appreciating how
tion in the development of goals and interventions for high-
body systems function, grow, and mature in utero. One of
risk infants and their families, including preventive care, (6)
the earliest-born fetuses that has survived was born at 21
discuss current, evidence-based resources for families and
weeks’ and 5 days’ gestation, a figure equal to approximately
other caretakers, (7) demonstrate clinical reasoning skills,

Thompson CR. Pediatric Therapy:

An Interprofessional Framework for Practice (pp 85-99).
- 85 - © 2018 SLACK Incorporated.
86 Section 6

TABLE 6-1
CRITICAL PERIODS OF FETAL DEVELOPMENT
BODY SYSTEM CRITICAL PERIODS CONTINUED RISK
DURING GESTATION
Central nervous system/brain prenatal 4 to 8 weeks Postnatal, through to
development adulthood
4 to 24 weeks Neuronal proliferation
6 to 30 weeks Neuronal differentiation
8 to 30 weeks Neuronal migration
10 weeks on Synapse formation
20 weeks on Programmed cell death
18 weeks on Synaptic pruning
30 weeks on Myelinization
Heart 5 to 9 weeks 12th week
Upper limbs 6 to 10 weeks 12th week
Eyes 6 to 10 weeks Term
Lower limbs 6 to 10 weeks 12th week
Teeth 9 to 11 weeks Term
Palate 9 to 11 weeks 16th week
External genitalia 9 to 11 weeks Term
Ears 6 to 11 weeks 13th week
Adapted from The Endowment for Human Development. Prenatal Summary. The Endowment for Human Development Web site. https://
www.ehd.org/prenatal-summary.php. Published 2017. Accessed December 5, 2017.

6 months of pregnancy.1,2 A fetus born before 24 weeks of Every fetus experiences critical periods in utero as it grows
pregnancy has a low chance of survival, and those who do and develops. These critical periods are when genetic or
survive often suffer from some type of disability. In review- maternal effects can significantly influence the develop-
ing embryological and fetal development, consider the risks mental process. Negative influences throughout pregnancy,
of a premature infant born as early as 6 months’ gestation. depending upon their timing, severity, and duration, can
The germination period begins at conception and lasts cause major congenital malformations incompatible with
approximately 2 weeks, at which point the embryonic period life or can significantly limit the structural and functional
begins. During the embryonic period, lasting until 8 weeks’ integrity of a newborn. Table 6-1 illustrates the critical peri-
gestation, the fetus forms from the undifferentiated embryo ods in development when negative influences can have the
to a human fetus with distinguishable body structures, a greatest impact on the fetus’ health.
process of organ formation described as organogenesis. At 8 Researchers have identified a range of negative influences
weeks, the fetal period begins and typically lasts until 38 on fetal development. Teratogens are harmful agents that can
to 42 weeks (full-term), when the neonate is equipped to enter the womb, typically through maternal experiences,
leave the womb. This gestational period is divided into 3 and result in birth defects.3,4 Teratogens include radiation,
trimesters, each lasting a period of approximately 3 months. chemicals, environmental pollutants, and infections. See
Gestational age (GA) is measured in weeks from the first day Table 6-2 listing well-known teratogens. Depending upon
of the woman’s last menstrual cycle to the current date and is the time and duration of exposure to these teratogens, they
commonly used to describe a premature infant’s age at birth. could have a significant impact on the infant’s mental and
For example, a neonate born 4 months early would typically physical health.
have a GA of 6 months.
 Interprofessional Care of High-Risk Infants 87

TABLE 6-2
TERATOGENS
DRUGS AND CHEMICALS IONIZING RADIATION (X-RAYS)
Alcohol HYPERTHERMIA
Aminoglycosides (Gentamicin)
INFECTION MICROORGANISMS
Aminopterin
Antithyroid agents (PTU) Coxsackie virus
Bromine Cytomegalovirus
Cigarette smoke Herpes simplex
Cocaine Parvovirus
Cortisone Rubella (German measles)
Diethylstilbesterol (DES) Toxoplasma gondii (toxoplasmosis)
Diphenylhydantoin MATERNAL METABOLIC CONDITIONS
Heroin
Autoimmune disease (eg, Rh incompatibility)
Lead
Diabetes
Methylmercury
Dietary deficiencies, malnutrition
Penicillamine
Phenylketonuria
Retinoic acid (Isotretinoin, Accutane)
Streptomycin
Tetracycline
Thalidomide
Trimethadione
Valproic acid
Warfarin
Adapted from Gilbert-Barness E. Teratogenic Causes of Malformations. Ann Clin Lab Sci. 2010:40;99-114.
Note: This list includes known and possible teratogenic agents and is not exhaustive.

A mother’s prenatal care is essential for assuring an opti- she also puts the growing fetus at increased risk during preg-
mal environment for the fetus’ healthy growth and develop- nancy.1 Other less controllable risk factors involve genetic
ment. What are common maternal risk factors contributing to conditions, such as single gene disorders (eg, cystic fibrosis
a high-risk pregnancy? Some maternal risk factors are control- or sickle cell disease) and chromosomal disorders (eg, Down
lable; that is, they are factors that are commonly addressed syndrome).5,6
in prenatal care, including unhealthy lifestyle behaviors, Pregnancy itself can pose risks, including problems with
such as cigarette smoking, drug abuse, or alcohol use, and the uterus, cervix, placenta, or amniotic fluid; incompatible
exposure to infectious agents (eg, sexually transmitted blood groups; and multiple births. Also, the birth process
infections and cytomegalovirus).1 For example, heavy and or delivery itself may be prolonged or traumatic, with risks
prolonged drinking by an expectant mother can cause fetal including fetal distress, breech position, placenta previa,
alcohol syndrome, a cluster of abnormalities that affect both meconium aspiration, nuchal cord, and cephalopelvic dis-
the infant’s mental and motor functions. In some cases, risk proportion.5,6 Finally, a family’s history of pregnancy com-
factors are less controllable. Living in poverty is associated plications or death of a baby during or following birth not
with increased incidents of illness, malnourishment, young only increases the risk to the health of subsequent children
teenage mothers, and stressful lifestyles; which all contribute but also creates an additional emotional strain on the expe-
to increased risk for the infant. If the mother is older than 35 rience of bringing a new baby into the world.5,6 Pediatric
or if she has pre-existing health conditions, such as asthma, therapists must be mindful of these additional stressors that
diabetes, obesity, high blood pressure, anemia, or epilepsy, families face when dealing with their high-risk infants.
88 Section 6

defects or abnormal maternal serum alpha-fetoprotein.5

PREMATURITY AND These tests include the following5:
LOW BIRTH WEIGHT • Amniocentesis: A low-risk prenatal diagnostic procedure
to determine the fetal age and genetic characteristics
A high-risk infant, whether put at risk by maternal or after 4 months’ gestation
other factors, is a neonate who, regardless of gestational age, • Fetal ultrasound: A diagnostic procedure producing an
birth weight, or size, is judged to have a greater-than-average image of the fetus
chance of morbidity particularly within the first 28 days of • Chorionic villi sampling or chorionic villus biopsy: A
life.5,6 Risk factors are varied and include preconceptual, biopsy at 9 to 12 weeks to detect chromosomal and
prenatal, natal, or postnatal conditions or circumstances metabolic abnormalities of the fetus
that interfere with the normal birth process or impede
• Fetoscopy: A procedure used to sample tissue for labo-
adjustment to extrauterine growth and development.6
ratory testing for potential metabolic and/or genetic
Factors commonly putting neonates at risk include pre-
abnormalities
maturity and low birth weight. Prematurity is defined as any
birth occurring prior to 38 weeks’ GA.7 The shorter the • Cordocentesis: A test involving percutaneous umbilical
infant’s GA, the greater the neonate’s risks for medical com- blood sampling and analysis
plications that impact brain development, health, and subse- • Cervical length measurement: A measurement to assess
quent developmental outcomes.8 This prematurity deprives fetal growth
the neonate of maternal support systems that allow essential • Lab testing for fetal fibronectin: A lab test associated with
body systems to develop and mature. Underdevelopment preterm labor
of key body systems jeopardize brain development and/or • A biophysical profile: An assessment that combines
health outcomes, potentially diminishing the infant’s ability fetal heart rate monitoring (nonstress test) and fetal
to fully develop skills and enjoy a high quality of life.9 ultrasound
Low birth weight is defined as any neonate born weigh- At birth, every neonate is screened using simple tests
ing less than 5 pounds (2500 grams), with very low birth that quickly identify infants who are an increased risk. The
weight defined at 3.3 pounds (1500 grams), and extremely Apgar score is used to score the newborn’s appearance, pulse,
low birth weight defined at 2.2 pounds (1000 grams).10 responsiveness, muscle activity, and breathing.20 Each cat-
Premature infants with low birth weight face a myriad of egory is scored with 0, 1, or 2 (2 being the highest rating
challenges, including elevated risks for sudden infant death and healthiest score), depending on the observed condition.
syndrome,11 heart and lung problems,12 intraventricular The 1-minute score determines how well the neonate toler-
hemorrhage,13 developmental impairments such as cerebral ated the birthing process, and the 5-minute score indicates
palsy,14 problems with feeding,15 behavioral disorders,16 how well the neonate is surviving outside of the womb.
impaired cognitive skills,17 chronic health problems (eg, The 1-minute Apgar score typically determines the need
asthma),18 and problems with vision and hearing.19 In gen- for immediate medical help. A score between 7 and 10 is
eral, the risks of these complications increase as GA at birth normal. Scores between 4 and 6 generally indicate the need
decreases. Some risk factors affect survival of the infant and for some help breathing, such as suctioning the nostrils or
must be addressed immediately, whereas others may not be giving the newborn oxygen. Scores of 3 or less may indicate
as identifiable until the child starts school and experiences the need for immediate lifesaving measures, such as resus-
learning challenges. citation. Babies born prematurely or delivered by Cesarean
section often have lower-than-normal scores, especially at
the 1-minute testing. A 5-minute Apgar score of 6 or less
IDENTIFYING HIGH-RISK INFANTS indicates the need for additional medical attention. Table
6-3 lists the criteria used for the Apgar score.
Given these potential problems, infants deemed high-risk A baby with a low Apgar score may need attention, such
undergo additional screening at birth. These tests are most as stimulation, to get the heart beating at a healthy rate,
commonly performed on mothers who are older than 35 supplemental oxygen, or help clearing out the airway to
with (1) a family history or other child with chromosomal improve breathing. Oftentimes, a low score at 1 minute is
abnormalities, (2) a known risk for a disorder that can be near normal by 5 minutes. Also, a lower Apgar score does
diagnosed in the fetus, and (3) children with neural tube not necessarily predict long-term health problems for the
 Interprofessional Care of High-Risk Infants 89

TABLE 6-3
APGAR SCORING
Activity (muscle tone)
0 ̶ Limp; no movement
1 ̶ Some flexion of arms and legs
2 ̶ Active motion

Pulse (heart rate)̶a critical test

0 ̶ No heart rate
1 ̶ Fewer than 100 beats per minute
2 ̶ At least 100 beats per minute
Grimace (reflex response to an irritating stimulus)
0 ̶ No response to airways being suctioned
1 ̶ Grimace during suctioning
2 ̶ Grimaces and pulls away, coughs, or sneezes during suctioning
Appearance (color)
0 ̶ Whole body is completely bluish-gray or pale
1 ̶ Good color in body with bluish hands or feet
2 ̶ Good color all over
Respiration (breathing)
0 ̶ Not breathing
1 ̶ Weak cry; may sound like whimpering, slow or irregular breathing
2 ̶ Good, strong cry; normal rate and effort of breathing

child. However, if the newborn needs ongoing care, she is

placed in the NICU for close monitoring and technological
ROLES OF PROFESSIONALS WORKING
support designed to stabilize the newborn’s physiological
status.
WITH PREMATURE AND HIGH-RISK
Premature infants are medically fragile because of their INFANTS
underdeveloped body structures and body functions. For
example, 90% of body weight is gained after 5 months’ GA, Professionals who work with these vulnerable neonates
with 50% of that weight gained in the final 2 months, so and their families must have excellent interprofessional
premature infants commonly appear very thin, wrinkled, knowledge and skills, focusing on their abilities to pro-
and fragile with underdeveloped body features. Similarly, vide care centered on each family’s needs. In addition to
the newborn will have lower muscle tone than the typical discipline-specific skills, these professionals have shared
full-term infant who has more fully developed and active knowledge across embryology and genetics, typical and
muscles. With this in mind, expectations for sensorimotor atypical infant development, ethical decision making, effec-
function should be adjusted to the infant’s GA rather than tive interdisciplinary teamwork, and family-centered care.21
chronological age. In addition to their shared knowledge, each professional
contributes unique knowledge and skills to facilitate the best
possible outcomes for these most fragile clients.
90 Section 6

Because the care of high-risk infants may be complex • Designing, implementing, and evaluating the efficacy
and demanding, teams often comprise a variety of medical of intervention plans in collaboration with the family
and rehabilitation professionals, including neonatologists, and medical team
nurses, respiratory therapists, speech-language pathologists, • Developing and implementing discharge plans in col-
occupational therapists, physical therapists, lactation consul- laboration with the family, medical team, and com-
tants, and social workers (Table 6-4). munity resources
• Consulting with providers of specialized equipment or
services in preparation for community-based care
THE NEONATAL INTENSIVE CARE UNIT • Consulting and collaborating with health care pro-
fessionals, families, policy makers, and community
The NICU offers a safe environment for the high-risk organizations to advocate for services to support the
infant and family. At birth, the neonate’s failure of any
development of the neonate
body system must be addressed with technology to replace
vital functions, such as air exchange, circulation, digestion, • Incorporating evidence-based literature into neonatal
excretion of waste, and immunologic functions. The NICU practice
combines advanced technology and trained professionals • Communicating, demonstrating, and evaluating neo-
to provide specialized care for these vulnerable neonates natal care procedures with NICU professionals and
designed to manage the needs of the family and newborn. other caregivers
Tests commonly administered in the NICU include the • Developing an interprofessional risk management plan
following: • Evaluating the effectiveness of a neonatal program
• Blood tests for anemia, high levels of bilirubin (possible • All professionals working in the NICU should be famil-
jaundice), low blood sugar, chemical imbalance, infec- iar with common terminology to enhance interprofes-
tion, and blood gases sional communication. Table 6-5 lists terms associated
• Computed tomography (CAT or CT) scan with care of the high-risk infant. Table 6-6 lists the
• Echocardiogram types of care typically provided by pediatric therapists.
• Hearing test (brainstem auditory-evoked response test) The team approach to all of these issues surrounding
problems high-risk infants is paramount to the successful manage-
• Magnetic resonance imaging (MRI) ment of care. All team members must be mindful of the
• Newborn screening test (phenylketonuria [PKU] or daily demands of an infant and family in the NICU. This
newborn screening [NBS] test) awareness includes assessment of the neonate’s state of
arousal, sleep cycles, and the sensory environment (eg, light,
• Test for retinopathy of prematurity (ROP) sound, tactile input by caregivers, machinery in NICU).
• Ultrasound Additional considerations for collaboration involves rec-
• Urine tests for kidney function ognizing stressors of the neonate, the family, and other
• Weight caregivers; addressing their concerns; and providing needed
• X-rays education. Education may relate to proper handling, emo-
tional bonding, addressing the newborn’s neurodevelop-
• Tests for neurological maturation, such as the Milani- ment, and therapeutic positioning (eg, swaddling, kangaroo
Comparetti Motor Development Screening Test care, position changes). The NICU environment, associated
Pediatric therapists with expertise in the NICU work as with extensive monitoring devices and tubes, and medical
a team to ensure that the neonate has sufficient stimulation interventions impact the newborn’s sensorimotor function,
for optimal growth and development but avoids overstimu- so special attention is needed to prevent secondary complica-
lation to the newborn’s underdeveloped central nervous tions associated with these factors.
system. Other roles include the following22,23: The challenge of oral feeding is a specific example of the
• Screening neonate to determine needs for referral need for interprofessional management. Physicians, speech-
• Assessing the neonate’s body structures, body functions, language pathologists, lactation consultants, occupational
and neurodevelopment therapists, physical therapists, and nurses work together
• Developing and implementing a plan to prevent neu- to ensure the safety of oral nutrition for the infant and to
robehavioral disorganization and complications of pre- develop treatment plans working toward sufficiency of oral
maturity in multiple systems nutrition as a long-term goal.
 Interprofessional Care of High-Risk Infants 91

TABLE 6-4
INTERPROFESSIONAL TEAM MEMBER ROLES IN THE CARE OF HIGH-RISK INFANTS
PROFESSION ROLES AND RESPONSIBILITIES IN THE CARE OF REQUIRED TRAINING
HIGH-RISK INFANTS
Genetic counselor This professional offers genetic testing, education, and Master s degree and licensure in
counseling to patients and their families some states
Neonatologist This medical doctor provides critical care to neonates Degree in medicine with
and support to parents and other physicians in the completion of a 3-year
care of high-risk infants pediatric residency followed by
a 3-year residency in neonatal
specialization
Registered nurse This professional is responsible for evaluating, Bachelor s degree in nursing
coordinating, and administering health care plans that
may involve administering medications and nutrients,
monitoring of vital signs, providing specialized
respiratory care, and monitoring equipment used on
the infants
Speech-language This professional evaluates and implements treatment Master s degree in speech-
pathologist plans to address communication, cognition, feeding, language pathology
and swallowing in the developing infant within the
context of the family
Occupational This professional assists each family and infant to foster Master s degree or doctorate in
therapist optimal infant development across appropriate occupational therapy
occupations, sensorimotor processes, and
neurobehavioral organization
Physical therapist This professional diagnoses and manages movement Doctorate in physical therapy
dysfunction and enhances physical and functional
abilities, including preventing the onset, symptoms,
and progression of impairments, functional limitations,
and disabilities that may result from diseases, disorders,
conditions, or injuries and advising families regarding
optimal positioning for sleeping, handling, and feeding
Respiratory This professional manages respiratory support and Associate s degree in respiratory
therapist care for infants with compromised respiratory status care
Lactation This consultant assesses and implements strategies to There are several pathways to
consultant support the needs of the nursing mother and infant becoming an International Board-
and assists other health care providers with the Certified Lactation Consultant,
feeding needs of the infant but in general, medical course-
work and clinical preparation are
required
Social worker This professional provides support to families in areas Bachelor s degree in social work
such as environmental stress, physical illness, and
interpersonal conflicts and also performs
interdisciplinary team management, collaboration, and
discharge planning
Child life specialist This specialist provides educational and emotional Bachelor s degree in child
support for families while also working to enhance psychology (or a related field)
development for children in challenging situations and certification by the Child Life
such as hospitalization Council
92 Section 6

TABLE 6-5
HIGH-RISK INFANT CARE TERMINOLOGY
TERM DEFINITION
Adjusted age Also known as corrected age. This is the child s chronological age minus the number of
weeks early he was born.
Apnea A pause in breathing lasting 20 seconds or longer. Also known as an apneic episodes or
apneic spell.
Apgar score A numerical summary of a newborn s condition at birth based on 5 different scores,
measured at 1 minute and 5 minutes.
Bilirubin Yellow chemical that is a normal waste product from the breakdown of hemoglobin and
other similar body components. When bilirubin accumulates, it makes the skin and eyes
look yellow, a condition called jaundice.
Bronchopulmonary A chronic lung disease of babies, when the lungs do not work properly and the babies
dysplasia (BPD) have trouble breathing.
Brainstem auditory A hearing test where a tiny earphone is placed in the baby s ear to deliver sound. Small
evoked response sensors taped to the baby s head send information to a machine that measures the
test electrical activity in her brain in response to the sound.
Developmentally A term used to describe infants and toddlers who have not achieved skills and abilities
delayed/disabled that are expected to be mastered by children of the same age.
Extremely low birth A baby born weighing less than 2 pounds, 3 ounces (1,000 grams).
weight (ELBW)
Gastroesophageal Contents of the stomach coming back up into the esophagus, which occurs when the
reflex (GER) junction between the esophagus and the stomach is not completely developed or is
abnormal.
Gavage feeding Feeding a baby through a nasogastric (NG) tube. Also called tube feeding.
Gestation The period of development from the time of fertilization of the egg until birth. Normal
gestation is 40 weeks; a premature baby is one born at or before the 37th week of
pregnancy.
Hydrocephalus Abnormal accumulation of cerebrospinal fluid within the ventricles of the brain.
Intrauterine growth A condition in which the fetus doesn t grow as big as it should while in the uterus.
retardation (IUGR) These babies are small for their gestational age, and their birth weight is below the 10th
percentile.
Low birth weight A baby born weighing less than 5.5 pounds (2500 grams) and more than 3 pounds,
(LBW) 5 ounces (1500 grams)
 Interprofessional Care of High-Risk Infants 93

TABLE 6-6
INTERPROFESSIONAL CARE BY PEDIATRIC THERAPISTS IN THE NEONATAL INTENSIVE CARE UNIT
DISCIPLINE ROLES AND RESPONSIBILITIES
Shared knowledge • Understands medical terminology, pathophysiology, diagnostics, equipment,
infection control, lab tests used in the NICU, and medical precautions postsurgery
• Knows prenatal development and risk factors following premature birth (including
risks of the NICU environment)
• Appreciates the roles and responsibilities of team members in the NICU
• Embraces the philosophy of family-centered care
• Applies the International Classification of Functioning, Disability and Health (ICF)
Model to examination and intervention
• Engages in interprofessional collaboration, group dynamic processes, and family
education
• Values ethical practice
Interprofessional • Communicates and collaborates interprofessionally and with others involved in the
skills infant s care
• Determines optimal times for interactions (eg, screenings, examinations, and
interventions) based upon the neonate s tolerance and family routines
• Screens for need for needed services (eg, physical therapy, occupational therapy,
speech-language pathology)
• Incorporates evidence-based literature in neonatal practice
• Monitors and evaluates impact of recommended interventions
• Instructs, consults, and communicates with family members, caregivers, team
members, and community, as appropriate, during stay in NICU and after discharge
• Embraces family-centered care and cultural competency
• Consults in areas of expertise and collaborates with health care professionals, families,
policy makers, and community organizations to advocate for services to support
families and their infant
• Advocates for families and their infants and help families become self-advocates
• Provides documentation that is objective, interpretive, thorough, and concise
(continued)

The complexity of care involved in addressing feeding

INTERPROFESSIONAL MANAGEMENT OF issues is best addressed through a highly coordinated team
FEEDING effort. Team members are often defined based on the etiol-
ogy of the feeding issues and contributing medical condi-
One example of high-risk infant care that requires a tions. At the core of this team is the family, the significance
coordinated team effort is feeding. Optimum nutrition is a of which is highlighted in the next section. Medical person-
critical factor in managing the medical needs of extremely nel, including the neonatologist, speech-language patholo-
low birth weight, very low birthweight, and low birth gist, occupational therapist, physical therapist, nutritionist,
weight preterm infants. The oral, pharyngeal, and digestive and lactation consultant, function as a team to coordinate
tract structures and functions have not fully developed suf- the feeding and nutritional needs of the infant and fam-
ficiently to support oral intake. In addition to prematurity, ily. An infant experiencing significant respiratory problems
other medical conditions may necessitate alternate means of may benefit from having the respiratory therapist on the
nutrition for newborns. team. A cardiologist would be a key member of the multi-
disciplinary team for an infant with cardiac issues. Because
94 Section 6

TABLE 6-6 (CONTINUED)

INTERPROFESSIONAL CARE BY PEDIATRIC THERAPISTS IN THE NEONATAL INTENSIVE CARE UNIT
DISCIPLINE ROLES AND RESPONSIBILITIES
Physical therapy • Interviews the family for family history and observes infant-parent caregiving patterns to
determine need for additional support
• Examines and evaluates the neonate using standardized tests and measures and assess
the various aspects outlined in the ICF Model (eg, Test of Infant Motor Performance,
Neonatal Behavioral Assessment Scale, Premature Infant Pain Profile, General Movement
Assessment, Hammersmith Neonatal Neurological Examination) (see Appendix B for a
more comprehensive list)
• Develops and implements a plan to prevent neurobehavioral disorganization and
complications of prematurity in multiple systems
• Using clinical reasoning, designs, implements, and evaluates plans of care and
therapeutic strategies appropriate to the infant s physiological, motor, and state
regulation strengths and vulnerabilities and neurodevelopmental risk in collaboration
with the family and NICU team; interventions may include handling, hydrotherapy,
splinting, taping, range of motion, therapeutic positioning, soft tissue mobilization,
adaptive equipment use, and developmental activities and strategies to prevent
deformities, increase function, and optimize environmental support
• Monitors autonomic, behavioral state, motor stability, skin integrity, equipment safety,
pain, and vital signs
• Develops and implements discharge plans, including consultation with providers of
specialized equipment or services in preparation for community-based care, and
educates families, caregivers, and community members about potential risks and
injuries related to toys and equipment (eg, seating devices, walkers), risks for deformity
(eg, asymmetrical head positioning), and risks for developmental delays (consistent
supine positioning)
Adapted from American Physical Therapy Association. Neonatal physical therapy practice: Roles and training. American Physical Therapy
Association Web site. http://www.apta.org/NICU/NeonatalPractice/RolesandTraining/PDF/. Accessed March 22, 2017 and Sweeney JK,
Heriza CB, Blanchard Y. Neonatal physical therapy; part I: clinical competencies and neonatal intensive care unit clinical training models.
Pediatr Phys Ther. 2009;21(4):296-307.

(continued)

gastrointestinal issues are common among high-risk infants, apnea or bradycardia can result in delays in establishing oral
a gastroenterologist may be a member of an infant’s team. feeding. These challenges are met by the team, including
Therefore, the care team for an infant will comprise profes- pediatric therapists who address the functional and struc-
sionals from many disciplines. The team is determined spe- tural needs of the growing and developing premature infant.
cifically according to an infant’s specialized care needs. This Many high-risk infants require mechanical ventilation
highly specialized team will determine how to best meet and gavage feedings to support growth and maturation.
the infant’s nutritional needs in light of physiologic state, Addressing the feeding and nutritional needs of high-risk
respiratory status, cardiac status, and ability to be fed orally. infants is integral for supporting physical growth, neuro-
Research suggests that the prognosis for a high-risk infant to developmental maturation, and addressing comorbid con-
develop independent feeding skills is highly dependent on ditions. The impact of poor nutritional status and failure
the maturation of the reflexive actions involved in respira- of growth can be devastating and have long-term conse-
tory coordination during feeding, pharyngeal, and glottal quences. Therefore, the well-coordinated collaboration of
closure reflexes for airway protection and esophageal reflex- a dedicated team is critical for advancing the best possible
es. Additionally, cardiac and respiratory challenges such as outcome for high-risk infants and their families.
 Interprofessional Care of High-Risk Infants 95

TABLE 6-6 (CONTINUED)

INTERPROFESSIONAL CARE BY PEDIATRIC THERAPISTS IN THE NEONATAL INTENSIVE CARE UNIT
DISCIPLINE ROLES AND RESPONSIBILITIES
Occupational • Selects and administers formal and informal assessment procedures to identify
therapy developmental abilities, vulnerabilities, and limitations in daily life activities and
occupations as they are influenced by medical status and neurobehavioral organization,
sensory development and processing, motor function, pain, daily activity (eg, feeding),
and social-emotional development, physical environment, caregiving practices,
positioning, and nurturance on the infant s neurobehavioral organization, sensory, motor,
and medical status
• Formulates an individualized therapeutic intervention plan that supports the infant s
current level of function and facilitates optimal social-emotional, physical, cognitive, and
sensory development of the infant within the context of the family and the NICU
• Modifies sensory aspects of physical environment according to infant sensory threshold
• Participates with the infant and caregivers in occupational therapy interventions that
reinforce the role of the family as the constant in the life of the infant and support the
infant s medical and physiological status to enhance infant neurobehavioral organization;
facilitate social participation; promote optimal infant neuromotor functioning and
engagement in daily life activities; promote developmentally appropriate motor function
and engagement in daily life activities through the use of biomechanical techniques,
when appropriate; and facilitate well-organized infant behavior through adaptation of
infant daily life activities
• Incorporates the occupational therapy program into NICU routines
Adapted from American Occupational Therapy Association. Specialized knowledge and skills for occupational therapy practice in the
neonatal intensive care unit. American Occupational Therapy Association Web site. http://www.aota.org/-/media/corporate/files/practice/
children/browse/ei/official-docs/specialized%20ks%20nicu.pdf. Accessed March 22, 2017.

Speech- • Conducts clinical assessment of the infant and family for communication, cognition,
language feeding, and swallowing problems
pathology • Conducts instrumental evaluation of the infant for feeding and swallowing problems
• Provides support and intervention/treatment for the infant s communication, cognition,
feeding, and swallowing problems (eg, facilitate nutritive sucking process in the
development of bottle feeding and breastfeeding)
• Establishes an intervention plan with the parent and caregiver training to facilitate the
development of safe feeding and swallowing skills
• Provides education, counseling, and support to families, other caregivers, and staff
regarding preferred practices in the NICU to support current and future communication,
cognition, feeding, and swallowing skills
Adapted from American Speech-Language-Hearing Association. Knowledge and skills needed by speech-language pathologists providing
services to infants and families in the NICU environment. American Speech-Language-Hearing Association Web site. http://www.asha.org/
policy/KS2004-00080/. Accessed March 23, 2017 and Garcia-Tormos LI, Garcia-Fragoso L, Garcia-Garcia IE. Role of the speech pathologist:
language in the neonatal intensive care unit. Bol Asoc Med P R. 2013;105(4):56-59.

the infant for extended periods of time while the infant

FAMILY SYSTEMS THEORY AND receives life-sustaining care.24 When they are able to see and
HIGH-RISK INFANTS hold the infant, parents are often surprised by the environ-
ment of the NICU and the appearance of the infant, who
The NICU environment places unanticipated and stress- may be connected to specialized equipment such as incuba-
ful demands on parents and families of high-risk infants. tors, feeding tubes, and respiratory support systems. Bonding
Parents may have to deal with not being able to see or touch and attachment in this type of environment is a challenge,
96 Section 6

and the negative impact of the situation on mothers and Use of this approach is critical because it sets the stage for
fathers has been well documented by researchers.25-27 future interactions with professionals that families will
One method of analyzing the ways that families manage encounter as their infant grows. Developing a relationship of
the myriad of challenges for an infant with severe disabilities trust and respect with the family reaps rewards for ongoing
is through use of a family systems theory approach. Family collaborative care.
systems theories recognize the complexity of relationships
and how one family member’s problem(s) or change(s) can
impact others in a family. Highlighted by these theories is ETHICAL CONSIDERATIONS
the knowledge that families are more than the sum of their
parts. To fully understand the family as a system, one must The NICU represents a medical environment that has
look at the whole. Although various systems theories related experienced growing medical and legal ethical dilemmas
to families exist, one theory (proposed by Turnbull et al28), and pressures related to the care of medically fragile, high-
offers a way to explore families from a strengths-based rather risk infants. Medical advances in neonatal technology and
than problem-based perspective. This approach emphasizes pharmacology have significantly improved the survival rates
resources used by the family rather than problems experi- of preterm, high-risk infants. These advances have raised
enced by the family, thus accentuating the strengths of the ethical considerations related to the family role in decision
family.29 The 4 components of this framework include (1) making, informed consent, and the extent to which medical
family structure, (2) family interaction, (3) family life cycle, intervention will be delivered.30-34
and (4) family functions29: The care of high-risk infants involves complex and criti-
• Family structure includes the number and type of family cal decision making. There are different models that range
members; individual characteristics of family members along a continuum from medical provider autonomy to
across cognitive skills, coping strategies, and health family-directed decision making.33 Medical professionals
needs; and the cultural and ethnic components of the and families face the challenge of balancing the family
family. Exploration of family structure includes the role with medical expertise. To fully participate in decision
members’ values, customs, and other cultural beliefs. making, families need sufficient information. Yet while
• Family interaction encompasses marital, parental, sib- navigating the emotional and physical demands of caring
ling, and extrafamilial subsystems. The contributions for a sick infant, families may struggle with the amount of
of siblings or grandparents as resources for parents of information and the complexity of technical medical infor-
high-risk infants are valuable assets. Likewise, the stress mation to sufficiently offer informed consent. In facilitating
related to siblings of children with special needs (eg, informed consent, physicians may also face the dilemma of
siblings’ feelings of being forgotten or overlooked) are attempting to determine the family’s readiness for informa-
important considerations in this family systems model. tion. Additionally, medical providers may face challenges
The ways that members of a family relate to each other in determining whether to provide neutral, objective prog-
are important aspects of family interactions. As parents nostic information that allows families to make decisions
become older, siblings may adjust to more of a primary or to provide recommendations that allow families to make
caregiver role for both the parents and the individual choices. Families will process information within the con-
with special needs. text of their religious and cultural beliefs. Each family will
have a unique perspective for how technical, medical, and
• Family life cycle includes changes of time that occur
prognostic information is combined with religious and cul-
within families. These changes can be structural (eg, tural beliefs and practices for making informed decisions.
the addition of family members) or developmental (eg,
Advances in care options supported by medicine and
a sibling reaching an independent or rebellious age).
technology have greatly increased the viability of extremely
As individuals within the family age, this can have an preterm infants. As such, decisions related to administering
important impact on the resources available for manag- or withholding treatment for infants at the limits of viability
ing the needs of a child with special needs. presents one example of an ethical dilemma. In addition to
• Family functions consist of the various individual needs the ethical dilemma, there are legal and emotional chal-
of each member. Functions are varied and include lenges for the medical team and the families. Therefore,
everything from health care resources to money or decision making related to treatment options or related to
warmth between family members. These are the things the withholding or withdrawing of treatment is a complex
that each member needs to thrive and be successful. process that is guided by diagnosis and prognosis, informed
Too many unmet needs may result in significant stress consent with considerations for futility of treatment, quality
for the family members, whereas adequate management of life, and parental-caregiver counseling.
of family function resources may be an area of strength.
 Interprofessional Care of High-Risk Infants 97

Medical providers and families engaging in shared deci- 1. Communicate with the family about early interven-
sion making may find that roles shift depending on the criti- tion (EI) options and determine if they are ready for
cal nature or urgency of a decision. Decisions in intensive a referral.
care units often involve critical life-or-death circumstances. 2. Communicate between the hospital team and the EI
Convening a team and family for information sharing and team about the infant’s developmental/health status
collaborative decision making may not always be an option. and discharge plan, following parental consent to
In such cases, the ethical practice guidelines that govern release information.
medical providers will support critical decision making. 3. Ask the family for their preferences for the time and
location of the first visit.
4. Describe early intervention as a system of family-
PREVENTIVE CARE and child-centered supports, services, and resources
designed to assist parents in helping their child infant
Some families raise questions about the risks of having grow and learn. This explanation includes informa-
additional children with similar problems. This presents an tion about the Program for Infants and Toddlers
opportunity for the interprofessional team to share informa- with Disabilities (Part C of IDEA), a federal grant
tion with families regarding prenatal care to minimize the program that assists states in operating a comprehen-
risk to their future newborns. Within the role of profession- sive statewide program of EI services for infants and
als promoting health, therapists should provide information toddlers with disabilities (birth through 2 years) and
about the following: their families.
• Seeking prenatal care as soon as possible in the pregnancy 5. Talk to the family members about their experiences,
• Engaging in healthy lifestyle practices (eg, proper diet, concerns, and priorities as they transition to EI.
adequate sleep, managing stress, stopping smoking, 6. In preparation for the evaluation and assessment that
avoiding alcohol) precedes the initiation of EI services, ask family mem-
• Discussing the benefits and risks of over-the-counter bers about how they would like to participate in the
medications, prescription medicines, vitamins, and process and share this information with EI services.
supplements 7. Encourage families to engage in support groups and
• Discussing the benefits and risks of assisted reproduc- services that ease this transition process.
tive technology (ART) because multiple pregnancies
carry a higher risk of preterm labor
• Suggesting ways to reduce maternal exposure to terato- SUMMARY
gens, including insecticides, solvents, lead, mercury,
paint (including paint fumes), and animal urine and Pediatric therapists working with high-risk infants may
feces encounter these newborns and their families while work-
This is a good opportunity to emphasize the importance of ing in the NICU or after their transition to EI services, if
maintaining lifelong health, fitness, and wellness habits to needed. Professionals working in this setting must be knowl-
ensure optimal health for the infant and the entire family. edgeable about prenatal growth and development, highly
skilled in NICU care, and able to work collaboratively with
others to ensure that the family and newborn are given high-
TRANSITIONING FROM THE quality care. The roles of professionals, although distinct,
may overlap when offering collaborative care based upon a
HOSPITAL TO EARLY INTERVENTION family systems theory approach. Additional considerations
must be given to the ethical issues unique to infants who
Once the neonate with special needs has stabilized physi- are physiologically unstable and in critical condition. Each
ologically, she can be discharged to the home and receive pediatric therapist, whether working in the NICU or not,
follow-up care, as needed. The transition from the hospital needs to be an advocate for prenatal health to reduce the risk
to the home can be challenging for many parents but can be of high-risk pregnancies.
facilitated by professional guidance. The Division for Early
Childhood (DEC) of the Council for Exceptional Children
provides helpful interprofessional guidelines to ease the
transition35:
98 Section 6

eventually destroys the ability of the muscles to function.

INTERPROFESSIONAL ACTIVITIES Meredith’s parents were advised that Sara was probably the
carrier of the disease and they should strongly consider not
Teamwork in the having additional children. Her parents are preparing to
Neonatal Intensive Care Unit transition from the NICU to the home setting.
1. Review the terminology, roles, and issues in the fol- Working With the Family of a
lowing case study.
2. Distinguish the roles and responsibilities related to
High-Risk Infant
assessments, including your choices of assessment Watch the movie little man (http://www.littlemanthe-
selection. movie.com). After watching the movie, answer the following
3. As a team, determine a plan of care that addresses key questions as a team:
concerns. 1. Characterize the strengths and needs of each family
member.
2. Discuss your respective roles in the NICU vs in the
home setting.
3. Discuss family stressors witnessed throughout the
film.
4. Collaborate on resources to help the family.
Case 6-1: A 1-month-old girl born with 5. Describe potential conflicts observed between the
myotonic muscular dystrophy and cleft palate family members and professionals and ways to reduce
conflict.
Meredith is a 1-month-old girl born with myotonic
muscular dystrophy and cleft palate. When her mother, 6. Work together to formulate a plan to meet the needs
Sara, was 7 months pregnant, she was at work as a librar- of the child and the family in the NICU and the home
ian when she suddenly felt ill and became concerned about setting for therapeutic positioning, feeding, and fam-
her unborn child. She called her husband, James, a police ily engagement, and/or other identified needs.
officer, telling him she was heading to the hospital and to
meet her there. Once they both arrived at the hospital, Sara Case 6-2: A high-risk infant transitioning to
was admitted to labor and delivery. After several unsuccess- his home
ful attempts to stop the progression of labor, baby Meredith
was born weighing 3.5 pounds and showing signs of distress, The movie little man presents the story of a boy with
including bradycardia and respiratory distress. Meredith was multiple impairments transitioning from the NICU envi-
admitted to the NICU with an Apgar score of 3 out of 10 ronment to the home environment. Clips of little man by
at 5 minutes after delivery. Sara and James were inconsol- Nicole Conn are available on YouTube, and the entire movie
able, faced with what felt like an insurmountable task of is available on demand at Vimeo (https://vimeo.com/onde-
being with their baby in the NICU and an uncertain future. mand/littleman). According to the site:
Immediately, the NICU team (involving neonatologists, little man is Nicole Conn’s award-winning documen-
respiratory therapists, nurses, and pediatricians) stabilized tary about her micro-preemie son, Nicholas, born
Meredith’s respiratory status, determined the best methods 100 days early, as he struggles for survival. When
for providing nutrition to Meredith, and further examined Nicholas is born 100 days early, he weighs only one
Meredith to discover an incomplete unilateral cleft palate. pound and faces impossible odds for survival. As he
Meredith was not yet stable enough for her parents to be struggles for life, so struggle his two mothers: out
involved in her care, and they felt helpless to do anything. lesbian filmmaker Nicole Conn and political activist
Given Meredith’s respiratory status, cleft palate, and pre- Gwen Baba, to keep their family from disintegrating
maturity, she was given a nasogastric tube for nutrition. under the unrelenting stress and chaos of hospitals,
The speech-language pathologist consulted with the parents emergency medical crises and a crushing blow to trust.
regarding Meredith’s cleft palate. Over the next several days, The winner of 12 Best Documentary awards at film
additional concerns arose regarding Meredith’s hypotonia festivals across the country, little man explores the core
and lack of improvement in respiratory status. The NICU of the human spirit as a family realizes that they are
team collaborated, discussing lab tests, tests of motor func- capable of enduring what they never thought possible.
tion, and observations to determine what else was affecting
Meredith. Eventually, a geneticist determined the diagnosis
of myotonic muscular dystrophy, a progressive disease that
 Interprofessional Care of High-Risk Infants 99

19. Thompson LC, Gillberg C. Behavioural problems from perinatal and

REFERENCES neonatal insults. Lancet. 2012;379(9814):392-393.
20. Medline Plus. Apgar score. Medline Plus Web site. https://medlin-
1. Rochman B. A 21-week-old baby survives and doctors ask, how eplus.gov/ency/article/003402.htm. Published November 20, 2014.
young is too young to save? Time Web site. http://healthland.time. Accessed January 27, 2017.
com/2011/05/27/baby-born-at-21-weeks-survives-how-young-is-too- 21. American Speech-Language-Hearing Association. Knowledge and
young-to-save/. Published May 27, 2011. Accessed January 24, 2016. skills needed by speech-language pathologists providing services to
2. Flanders N. Born at 22 weeks, youngest premature baby to survive infants and families in the NICU environment. American Speech-
in Israel leaves hospital. Liveaction Web site. http://liveactionnews. Language-Hearing Association Web site. www.asha.org/policy/
org/born-22-weeks-youngest-premature-baby-survive-israel-leaves- KS2004-00080/. Published 2004. Accessed May 1, 2017.
hospital/. Published September 5, 2016. Accessed January 24, 2016. 22. Sweeney JK, Heriza CB, Blanchard Y. Neonatal physical therapy; part
3. Gilbert-Barness E. Teratogenic Causes of Malformations. Ann Clin I: clinical competencies and neonatal intensive care unit clinical train-
Lab Sci. 2010:40;99-114. ing models. Pediatr Phys Ther. 2009;21(4):296-307.
4. Gilbert S. Environmental disruption of normal development. In: 23. Sweeney JK, Heriza CB, Blanchard Y, Dusing SC. Neonatal physical
Developmental Biology. 6th ed. Sunderland, MA: Sinauer Associates; therapy; part II: practice frameworks and evidence-based practice
2000. https://www.ncbi.nlm.nih.gov/books/NBK9998/. Accessed guidelines [erratum in: Pediatr Phys Ther. 2010;22(4):377]. Pediatr
January 24, 2017. Phys Ther. 2010;22(1):2-16.
5. Mayo Clinic. High risk pregnancy: know what to expect. Mayo Clinic 24. Patterson D, Barnard K. Parenting of low birth weight infants: A
Web site. http://www.mayoclinic.org/healthy-lifestyle/pregnancy- review of issues and interventions. Infant Mental Health Journal.
week-by-week/in-depth/high-risk-pregnancy/art-20047012. Published 1990;11:37-56.
February 20, 2015. Accessed January 12, 2017. 25. Phillips S, Tooley G. Mothers’ and fathers’ experiences of complicated
6. Britton JR. The transition to extrauterine life and disorders of transi- childbirth. In: Kostanski M. The Power of Compassion: An Exploration
tion. Clin Perinatol. 1998;25:271-94. of the Psychology of Compassion in the 21st Century. New Castle,
7. World Health Organization. Preterm birth. World Health England: Cambridge Scholars Publishing; 2009:110-119.
Organization Web site. http://www.who.int/mediacentre/factsheets/ 26. Phillips S, Tooley G. Improving child and family outcomes following
fs363/en/. Published November, 2017. Accessed on December 28, 2017. complicated births requiring admission to neonatal intensive care
8. Hack M, Taylor H, Klein N, Mercuri-Minich N. Functional limita- units. Sexual and Relationship Therapy. 2005;20:431-442.
tions and special health care needs of 10- to 14-year old children 27. Dudley M, Gyler L, Blinkhorn S, Barnett B. Psychosocial interven-
weighing less than 750 grams at birth. Pediatrics. 2001;106:554-560. tions for very low birthweight infants: Their scope and efficacy. Aust
9. Campbell D, Fleischman A. Limits of viability: dilemmas, decisions, N Z J Psychiatry. 1993;27(1):74-85.
and decision makers. Am J Perinatol. 2001;18:117-128. 28. Turnbull AP, Summers JA, Brotherson MJ. Working with families with
10. Gavhane S, Eklave D, Mohammad H. Long term outcomes of kan- disabled family members: A family systems perspective. Lawrence, KS:
garoo mother care in very low birthweight infants. J Clin Diagn Res. University of Kansas; 1984.
2016;10(12):SC13-SC15. 29. Ronnau J, Poertner J. Identification and use of strengths: A family
11. Malloy MH. Prematurity and sudden infant death syndrome: United systems approach. Children Today. 1993;22:20-23.
States 2005-2007. J Perinatol. 2013;33:470-475. 30. Alderson P, Hawthorne J, Killen M. Parents’ experiences of sharing
12. Baraldi E, Filippone M. Chronic lung disease after premature birth. N neonatal information and decisions: Consent, cost, and risk. Soc Sci
Engl J Med. 2007;357(19):1946-1955. Med. 2006;62(6):1319-1329.
13. Stewart AL, Reynolds EO, Lipscomb AP. Outcome for infants 31. da Costa DE, Ghazal H, Khusaiby SA. Do not resuscitate orders and
of very low birthweight: Survey of world literature. Lancet. ethical decisions in a neonatal intensive care unit in a Muslim com-
1981;1(8228):1038-1040. munity. Arch Dis Child Fetal Neonatal Ed. 2002;86:F115-F119.
14. Kulak P, Macjorkowska E, Goscik E. Selected risk factors for spastic 32. Payot A, Gendron S, Lefebvre F, Doucet H. Deciding to resuscitate
cerebral palsy in a retrospective hospital-based case control study. extremely premature babies: How do parents and neonatologists
Progress in Health Sciences. 2014:4. engage in the decision? Soc Sci Med. 2007;64(7):1487-1500.
15. Jadcherla SR, Wang M, Vijayapal AS, Leuthner SR. Impact of pre- 33. Orfali K. Parental role in medical decision-making: fact or fiction?
maturity and co-morbidities on feeding milestones in neonates: A A comparative study of ethical dilemmas in French and American
retrospective study. J Perinatol. 2010;30:201-208. neonatal intensive care units. Soc Sci Med. 2004;58(10):2009-2022.
16. Klein VC, Gaspardo CM, Martinez FE, Grunau RE, Linhares MB. 34. Walther FJ. Withholding treatment, withdrawing treatment, and
Pain and distress reactivity and recovery as early predictors of tem- palliative care in the neonatal intensive care unit. Early Hum Dev.
perament in toddlers born preterm. Early Hum Dev. 2011;85:569-576. 2005;81:965-972.
17. Milner KM, Neal EFG, Roberts G, Steer AC, Duke T. Long term neu- 35. Early Childhood Technical Assistance Center. Transition from
rodevelopmental outcome in high-risk newborns in resource limited Hospital to Early Intervention Checklist. Early Childhood Technical
settings: A systematic review of the literature. Paediatric International Assistance Center Web site. http://ectacenter.org/~pdfs/decrp/TR-1_
Child Health. 2015;35:227-242. Hosp_to_EI_2017.pdf. Published 2017. Accessed on December 5,
18. Laughon M, Allred EN, Bose C, et al. Patterns of respiratory distress 2017.
in the first two postnatal weeks of extremely premature infants.
Pediatrics. 2009;123(4):1124-1131.
Section 7
Teamwork in Early Intervention
Catherine Rush Thompson, PT, PhD, MS and Lauren Little, PhD, OTR/L

OVERVIEW NUTS AND BOLTS OF EARLY

Children younger than 3 who are at risk for developmen- INTERVENTION SETTINGS
tal problems benefit from early intervention (EI), a federally
funded, coordinated system of therapeutic services that sup- The Individuals with Disabilities Education
ports families in the prevention of developmental delays.1 Act
This section discusses how children qualify for EI and how
interprofessional teams in the EI setting serve families. The Individuals with Disabilities Education Act (IDEA),
There are 2 overarching topics included in this section: (1) first enacted in 1997, ensures that all children with dis-
an overview of the Individuals with Disabilities Education abilities are entitled to a free appropriate public education
Act (IDEA), including interprofessional screening tools to meet their unique needs and prepare them for further
and practices, and the Individualized Family Service Plan education, employment, and independent living.1,2 IDEA
(IFSP), and (2) a discussion about working with parents and has 4 distinct sections; A, B, C, and D, with Part A laying
caregivers in EI, including parent advocacy, parental strain, out the basic foundation for the rest of the Act1:
parenting styles, promoting parent responsiveness and play, • Part A is titled “General Provisions, Definitions and
and supporting families transitioning from EI to school-age Other Issues” and describes the purpose and provisions
programs. of the law.
• Part B is titled “Assistance for Education of All Children
with Disabilities” and provides services and funding for
children with special needs, generally beginning at age 3.

Thompson CR. Pediatric Therapy:

An Interprofessional Framework for Practice (pp 101-114).
- 101 - © 2018 SLACK Incorporated.
102 Section 7

• Part C is titled “Infants and Toddlers with Disabilities.” and efficient EI services to each family.2,3 Options for these
Part C, most relevant to the provision of EI services, services may include a wide range of sites,2,3 including the
defines an “at-risk infant or toddler” as a child under 3 home and community, as well as specialized center-based
years of age who is at risk of experiencing a substantial programs, including EI centers, clinics, and hospitals offer-
developmental delay if EI services were not provided.1,2 ing specialized family services for young children. Families
As such, Part C addresses the needs of families of chil- may benefit from EI services across a variety of program-
dren with special needs through a comprehensive child ming sites. For example, therapists may work with families
find system and the Individual Family Service Plan in the home, consult with the infant’s day care provider,
(ISFP) to reduce the effects of developmental conditions engage with grandparents in their home, and/or provide
through coordinated EI services. services in a weekly group therapy session at a community-
• Recognizing the importance of ongoing research and based EI program to ensure consistent care. Services may
include the parent and child meeting with service providers
quality improvement, Part D of IDEA focuses on the
in the community (eg, a caregiver and child meeting with
need to improve special education programs, prepare
a service provider at a playground), groups of families and
personnel, disseminate information, support research,
their children meeting in one setting (eg, developmental
and apply research to special education.
therapy groups), and support groups for caregivers (eg, fam-
ily members participating in a group to address common
Individuals with Disabilities Education concerns).3 The EI team needs to work collaboratively as it
Act Part C coordinates goals across settings and delivers services that
IDEA Part C mandates that all states must provide best meet each family’s individualized needs.
EI services for at-risk children from birth to their third Although EI offers this rich array of child, parent, and
birthday.2 The range of EI services provided by federal family supports, professionals need to be mindful of fami-
law includes support to address potential problems with lies’ individualized needs and perceptions of support for
physical, cognitive, communication, adaptive and social, their children. In other words, practitioners must under-
or emotional development. IDEA Part C further mandates stand that parents’ perceptions of and expectations for
that EI services must be provided by qualified personnel, in services can significantly impact intervention outcomes.4 In
natural environments, and at no cost to families (except in one study of the transition from the neonatal intensive care
states that provide for a system of payment, such as a sliding unit (NICU) to home, mothers had varying perceptions
scale).2 of EI programs; those with high expressed needs benefited
Families are eligible for physical therapy, occupation- more from intervention, whereas those with low expressed
al therapy, and speech-language pathology services.1-3 needs showed fewer benefits.4 When assessed at 6 months
Additionally, families are eligible for the following1: (1) postdischarge, mothers with an increased expressed need for
audiological services to identify children with issues related to support benefited from EI programs; positive effects of the
hearing; (2) medical diagnostic services and nursing and health EI program included improvements in the mother’s sense of
services to manage health problems and promote healthy competence, perceived control, mood, and responsiveness.4
development; (3) nutrition services to address issues related Benefits were proportionate for the mothers who needed
to feeding, including food habits and food preferences; (4) the most support and those with infants with more severe
psychological services to assess and help manage issues such as disabilities. However, for mothers with low needs for sup-
the child’s behavior, learning, and mental health; (5) service port, participation in the EI program had negative effects
coordination to coordinate programs and therapies, based on outcomes. Clearly, the EI team must be sensitive to each
upon family needs; (6) social services to provide an assess- family’s expressed need for information and services, rec-
ment and resources for managing the social and emotional ognizing cultural differences, family concerns, and family
needs of the family; (7) special education for learning activi- strengths for engaging with their children.
ties that the family can use to promote the child’s develop-
ment; (8) vision services to assess and serve children with Interprofessional Screening Tools and
visual impairments; and (9) funding to support transporta- Practices
tion costs needed for families who must travel for needed
services. Table 7-1 lists the interprofessional care typically Although many infants are identified for EI following
provided by pediatric therapists in EI. discharge from the NICU, other infants have less obvious
developmental problems, and parents may not recognize
EI services are provided in the child’s natural settings
developmental delays. Professionals are often asked to pro-
that best meet the needs of the family. The EI team needs to
vide screenings that serve as a safety net for families with
be aware of the many options for service delivery and work
limited access to health care. There is a referral process that
together collaboratively to offer the most comprehensive
is commonly used to ensure that families and children have
 Teamwork in Early Intervention 103

TABLE 7-1
INTERPROFESSIONAL CARE BY PEDIATRIC THERAPISTS IN EARLY INTERVENTION
DISCIPLINE ROLES AND RESPONSIBILITIES
Shared knowledge • Knows typical infant and child development and developmental risk factors
• Understands common pediatric conditions (pathophysiology, clinical manifestations,
and prognoses)
• Appreciates the roles and responsibilities of team members in EI, including the family
• Embraces the philosophy of family-centered care
• Applies the International Classification of Functioning, Disability and Health (ICF)
Model to examination and intervention
• Understands the legal and philosophical underpinnings and implications of
Individuals with Disabilities Education Act (IDEA) Part C of 2004 (Public Law 108-446)
• Appreciates that EI should enhance the development of infants and toddlers,
(including cognitive, physical, communication, social-emotional, and adaptive
development) and enhance the capacity of families to meet the special needs of
their children
• Understands the Individualized Family Service Plan (IFSP) and its implementation
• Embraces play-based therapy
• Facilitates transition to and from EI
• Values ethical practice
Interprofessional • Communicates and collaborates interprofessionally and with others involved in the
skills child s care
• Determines optimal times for interactions (eg, screenings, examinations,
interventions) based upon the child s tolerance and family routines
• Screens for needed services (eg, physical therapy, occupational therapy, speech-
language pathology)
• Incorporates evidence-based literature in EI practice
• Monitors and evaluates impact of recommended interventions
• Instructs, consults, and communicates with family members, caregivers, team
members, and community, as appropriate
• Embraces family-centered care and cultural competency
• Encourages interventions in the natural environments where families and their
children live, learn, and play
• Consults in areas of expertise and collaborates with health care professionals,
families, policy makers, and community organizations to advocate for services to
support families and their children
• Helps families become self-advocates
• Provides documentation that is objective, interpretive, thorough, and concise
(continued)
104 Section 7

TABLE 7-1 (CONTINUED)

INTERPROFESSIONAL CARE BY PEDIATRIC THERAPISTS IN EARLY INTERVENTION
DISCIPLINE ROLES AND RESPONSIBILITIES
Physical therapy • Interviews the family for history and goals
• Observes child s and family s routines related to the body structures growth and
development, functional and play activities, environmental factors (psychosocial and
physical), personal factors (lifestyle behaviors), and participation
• Examines and evaluates the child using standardized tests and measures that assess
the various aspects outlined in the ICF Model (See Appendix A for a list of tests and
measures used)
• Develops and implements a plan to promote overall development, healthy growth,
and the ability to move
• Using clinical reasoning, designs, implements, and evaluates plans of care and
therapeutic strategies appropriate to facilitate development
• Monitors postural alignment, therapeutic positioning, skin integrity, equipment safety,
pain, and vital signs, as needed
• Develops and implements transition plans, including consultation with providers of
specialized equipment or services in preparation for community-based care, and
educates families, caregivers, and community members about potential risks and
injuries related to toys (including motorized cars) and equipment (eg, seating devices,
walkers, assistive devices, orthotics), risks for deformity, and risks for
developmental delays
Adapted from American Physical Therapy Association. The role of physical therapy with infants, toddlers, and their families in early
intervention. Academy of Pediatric Physical Therapy Web site. https://pediatricapta.org/special-interest-groups/early-intervention/pdfs/
Role%20of%20PT%20in%20EI.pdf
Occupational • Selects and administers formal and informal assessment procedures to identify
therapy developmental abilities, vulnerabilities, and limitations in daily life activities and
occupations as they are influenced by medical status and neurobehavioral
organization, sensory development and processing, motor function, pain, daily
activity (eg, feeding), social-emotional development, physical environment,
caregiving practices, positioning, and nurturance on the child s neurobehavioral
organization, sensory, motor, and medical status
• Formulates an individualized therapeutic intervention plan that supports the child s
current level of function and facilitates optimal social-emotional, physical, cognitive,
and sensory development of the child within the context of the family, home,
and community
• Modifies sensory aspects of the physical environment according to the child s
sensory threshold
• Participates with the child and caregivers in occupational therapy interventions that
reinforce the role of the family as the constant in the life of the child and supports
the child s medical and physiological status to enhance neurobehavioral organization;
facilitate social participation; promote optimal neuromotor functioning and
engagement in daily life activities; promote developmentally appropriate motor
function and engagement in daily life activities through the use of biomechanical
techniques, when appropriate; and facilitate well-organized behavior through
adaptation of daily life activities
Adapted from American Occupational Therapy Association. Specialized knowledge and skills for occupational therapy practice in the
neonatal intensive care unit. American Occupational Therapy Association Web site. http://www.aota.org/-/media/corporate/files/practice/
children/browse/ei/official-docs/specialized%20ks%20nicu.pdf. Accessed March 24, 2017.

(continued)
 Teamwork in Early Intervention 105

TABLE 7-1 (CONTINUED)

INTERPROFESSIONAL CARE BY PEDIATRIC THERAPISTS IN EARLY INTERVENTION
DISCIPLINE ROLES AND RESPONSIBILITIES
Speech-language • Conducts clinical assessment of the child and family for communication, cognition,
pathology feeding, and swallowing problems
• Conducts instrumental evaluation of the child for feeding and swallowing problems
• Provides support and intervention/treatment for the child s communication,
cognition, feeding, and swallowing problems (eg, facilitate nutritive sucking process
in the development of feeding)
• Establishes an intervention plan with the parent and caregiver training to facilitate the
development of safe feeding and swallowing skills
• Provides education, counseling, and support to families, other caregivers, and staff
regarding preferred practices to support current and future communication,
cognition, feeding, and swallowing skills
Adapted from American Speech-Language-Hearing Association. Knowledge and skills needed by speech-language pathologists providing
services to infants and families in the NICU environment. American Speech-Language-Hearing Association Web site. http://www.asha.org/
policy/KS2004-00080/. Accessed March 23, 2017.

access to EI services. Most typically, the referral source to observing children’s spontaneous behavior. Also, pediatric
EI is a physician or nurse practitioner, but it may also be therapists are reminded that the infant’s age should be based
parents who suspect that their infants have a developmental upon the extent of prematurity and should be adjusted
delay or disability. Once referred, a professional informs the accordingly. For example, an infant born 2 months prema-
family about how to sign up for an EI program. An EI case turely would be tested at an age level that is 2 months less
manager or officer informs the family of their rights, reviews than her chronological age to adjust for the child’s actual
the list of evaluators, obtains insurance/Medicaid informa- level of maturation.
tion, and obtains other relevant information for setting up
evaluations. Motor Screening
Screenings and formal evaluations must be conducted
Observation is a critical skill for assessing young infants.
with the parents’ consent. The EI team should be familiar
In addition to recognizing delays in achieving developmen-
with state guidelines and standardized evaluations that
tal milestones, pediatric therapists should be aware of the
are used to determine eligibility for available services. (See
following red flags for motor issues that can be easily identi-
Appendix B for a list of assessments that may be used in EI.)
fied by observing the infant’s posture and movements5:
Evaluations should be written with an emphasis on family
• Birth to 3 months: The infant has difficulty lifting
priorities, routines, and the child’s unique needs. Reports by
each professional are submitted prior to meeting to develop head, has stiff legs with little or no movement, pushes
the IFSP. back with head, keeps hands fisted, and lacks arm
movement.
Once children have entered the EI system, they have
likely shown developmental delays in a number of areas, • At 6 months: The infant has a rounded back while
including motor, language, and/or cognition. Although an sitting, is unable to lift head up while prone, has poor
overview of comprehensive screening and evaluation for the head control, has difficulty bringing arms forward to
purposes of obtaining EI services is beyond the scope of this reach out, arches back and stiffens legs, holds arms held
section, there are many screening tools used by service pro- back, or has stiff legs.
viders once a child is receiving EI services. Most often, these • At 9 months: The infant predominately uses one hand,
screening tools can help identify infants needing additional has a rounded back, has poor use of arms in sitting,
services. In this section, we discuss how all members of the has difficulty crawling, uses only one side of body to
EI team can screen for the motor, visual, cognitive, social, move, unable to straighten back, or cannot take weight
and emotional development in young children. All pediatric on legs.
screenings begin with close observations of infants because • At 12 months: The infant has difficulty getting to stand
a great deal of information can be obtained from simply because of stiff legs and pointed toes; only uses arms to
106 Section 7

pull up to standing; sits with weight to one side; has for a later diagnosis of an autism spectrum disorder. The
strongly flexed or stiffly extended arms; needs to use interprofessional EI team can screen for children’s social-
hand to maintain sitting; does not babble, point, or emotional difficulties to guide treatment and involve family
make gestures. members in children’s therapy services to the fullest extent
The EI team should be alert to infantile myoclonic sei- possible. See Table 7-2 for screening tools appropriate for
zures, which are evidenced by a sudden contraction of the infants and toddlers.
trunk flexor muscles, possibly accompanied by abrupt flex-
ion of arms to the chest and thighs to the trunk.6 In some Nutritional Screening
instances, a sudden noise, some manipulation, or feeding High-risk infants commonly have difficulties with eating
precipitates an infantile myoclonic seizure; however, some- and digestion, so parents and other caretakers oftentimes
times the seizures occur just before the onset of true sleep or seek help with these problems. As part of an interprofes-
immediately on waking. Apneic episodes (ie, suspension of sional team, it is helpful to screen for these issues because
breathing), episodic nystagmus (ie, eyes making repetitive, IDEA Part C provides nutrition services to address these
uncontrolled movements), episodic changes in tone and/ concerns. If families have not had nutritional screenings, the
or color, and episodic sneezing may be seizure manifesta- team could either recommend one and/or ask if they have
tions. Petit mal, minor motor, psychomotor, and grand mal any concerns about the following 9:
seizures may all occur during infancy, but the minor motor • Concerns about their child’s weight or stature;
type is most common. When the EI team is alert to these
red flags, they can make additional examinations or referrals • Difficulties feeding (eg, how long it takes to feed; diffi-
that might be appropriate for the infant. culty swallowing, chewing, or sucking; problems eating
solids; delays in feeding skills);
Visual Screening • Problems with food intake (eg, food refusal, eating too
little, poor appetite);
All members of the EI team must be aware of how vision
• Concerns about hydration, bottle feeding, or formulas;
impacts all other areas of development; therefore, each mem-
ber is responsible for screening for any signs of visual impair- • Questions about the use of nutritional supplements and
ment. Red flags for visual problems include7 (1) appearance medications;
of any strabismus (cross-eyed) after 2 months of age; (2) • Gastrointestinal health concerns (eg, constipation, diar-
wandering, uncoordinated eye movements; (3) nystagmus rhea, and/or vomiting);
(dancing or jerky eyes); (4) holding items too close (within • Food allergies and/or food intolerances;
6 inches) for visual inspection; (5) turning the head to the • Problems with the use of a feeding tube;
side habitually to look at items; (6) having to turn the head
• Pica (ie, eating non-food items); and/or
to focus on people or objects in their periphery, or (7) disre-
garding objects presented in the peripheral field. Red flags • Dental issues (eg, teething problems).
for blindness7 include prolonged hand watching past devel- As part of a team who sees the family in the natural envi-
opmental age of 5 months (shadowing), staring at lights ronment, many of these issues can be addressed with family
in preference to people or objects, poking at eyes, rubbing education and referrals.
eyes, rocking, spinning, head banging, smelling, sniffing,
“rooting” to find objects, or prolonged mouthing of objects. Individualized Family Service Plan
For a full explanation of how to implement a vison screen-
Eligibility for services is based upon state criteria. For
ing for young children, refer to pages 17 to 23 in the Vision
example, Kansas outlines eligibility as:
Screening Guidelines outlined at http://health.mo.gov/liv-
ing/families/schoolhealth/pdf/VisionScreeningGuidelines. …children with developmental delay (experiencing
pdf. 25% or more between chronological age and devel-
opmental age, after correction for prematurity, and
Social-Emotional Screening as measured by appropriate diagnostic instruments
and procedures, in one of the following areas); or
Social-emotional screening tools assess children’s self- children under the age of three who are experienc-
awareness, social awareness, and relationships with caregiv- ing a discrepancy of 20% or more between chrono-
ers.8 Also, autism-specific screening tools often target social- logical age and developmental age, after correction
emotional components of child development and allow a for prematurity, and as measured by appropriate
service provider to assess a child’s risk for autism symptoms. diagnostic instruments and procedures, in two or
Specifically, autism-specific screening tools capture a child’s more of the following areas: (1) physical develop-
social interaction and communication difficulties, as well as ment including health and nutritional status, vision,
the presence of repetitive behavior, all of which are red flags
 Teamwork in Early Intervention 107

TABLE 7-2
SCREENING TOOLS FOR INFANTS AND TODDLERS
TOOL AGE AREAS OF DEVELOPMENT COMPLETION SOURCE OF
RANGE TIME INFORMATION
The Ages 1 month to Self-regulation, compliance, 10 to 15 Parent, caregiver
and Stages 5½ years communication, adaptive function, minutes (readability: less
Questionnaires-3 autonomy, affect, social interaction than 6th grade)
The Brigance 21 to 90 Fine motor, gross motor, language, daily 10 to 15 Parent, caregiver
Infant and months living, social-emotional skills minutes (readability: not
Toddler Screen rated)
Brief Infant- 12 to 36 Externalizing, internalizing, regulatory 7 to 10 minutes Parent, caregiver
Toddler Social months problems, maladaptive behaviors, 7 (readability: less
and Emotional scales of competences than 6th grade)
Assessment
Greenspan 0 to 42 Growing self-regulation and interest 10 minutes Parent, caregiver
Social-Emotional months in the world; engaging in relation- (qualified (readability: not
Growth Chart ships; using emotions in an interactive, examiner rated)
purposeful manner; using interactive needed for
emotional signals to communicate and scoring)
solve problems; using symbols to convey
intentions or feelings and express more
than basic needs; creating logical
bridges between emotions and ideas
Temperament & 11 to 71 Temperament; attention and 5 minutes Parent, caretaker,
Atypical Behavior months activity; attachment and social teacher
Scale behavior; neurobehavioral state; (readability: 3rd
sleeping; play; vocal and oral behavior; grade)
senses and movement; self-
stimulatory behavior in infants, toddlers,
and preschoolers
The Modified 24 to 36 Social interaction, communication, 5 minutes (If Parent, caregiver
Checklist for months repetitive behavior the MCHAT-R
Autism in indicates risk,
Toddlers-Revised a follow-up
interview is
necessary
Communication 6 to 24 7 language indicators: emotion and 10 minutes Parent, caregiver,
and Symbolic months use of eye gaze, use of communication, teacher
Behavior Scales use of gestures, use of sounds, use of (readability: not
Developmental words, understanding of words, and rated)
Profile-Infant use of objects
Toddler Checklist
Adapted from Henderson J, Strain PS. Screening for Delays and Problem Behavior (Roadmap to Effective Intervention Practices). Tampa,
FL: University of South Florida; 2009 and Wetherby A, Prizant B. Communication and Symbolic Behavior Scales Developmental Profile-
Preliminary Normed Edition. Baltimore, MD: Paul H. Brookes Publishing Co; 2001.
108 Section 7

hearing, and motor, (2) cognitive development, (3) completed. With the parents’ consent, EI services may
communication development, (4) social or emotional commence prior to the completion of the assessment.
development, or (5) self-help/adaptive development. • Content of Plan: the individualized family service plan
It also includes the professional judgment/informed shall be in writing and contain:
clinical opinion of the multidisciplinary team to 1. A statement of the infant’s or toddler’s present levels
conclude a developmental delay significant enough of physical development, cognitive development,
for eligibility when appropriate tests are not available communication development, social or emotional
or when testing does not reflect the child’s ability.10 development, and adaptive development, based on
New York State has similar criteria; however: objective criteria;
…to be eligible for the EIP [Early Intervention 2. A statement of the family’s resources, priorities, and
Program], the child must have a 12 month or 33% concerns relating to enhancing the development of
delay, or a score of at least 2 standard deviations the family’s infant or toddler with a disability;
below the mean, in an area of development (eg, 3. A statement of the measurable results or outcomes
communication development or social/emotion- expected to be achieved for the infant or toddler and
al development or physical development, etc).11 the family, including pre-literacy and language skills,
For this reason, some families move to different states to as developmentally appropriate for the child, and
optimize services for their children. the criteria, procedures, and timelines used to deter-
mine the degree to which progress toward achieving
Once it has been determined that a child is eligible for
the results or outcomes is being made and whether
services, the interprofessional team engages in an IFSP
modifications or revisions of the results or outcomes
meeting. At this meeting, parents and professionals must
or services are necessary;
work together to understand the child’s strengths and needs,
formulate family-centered goals, and discuss how to best 4. A statement of specific EI services based on peer-
serve the child and family. Based upon the important out- reviewed research, to the extent practicable, nec-
comes of this planning meeting, interprofessional competen- essary to meet the unique needs of the infant or
cies are essential. All must listen carefully to the outcomes toddler and the family, including the frequency,
desired by the family and be prepared to talk about options intensity, and method of delivering services;
that meet both the child’s and family’s needs. During this 5. A statement of the natural environments in which
meeting, EI services are specified, the plan is developed, EI services will appropriately be provided, including
and the family and representative for the state sign the IFSP. a justification of the extent, if any, to which the ser-
According to IDEA Part C,3 each family must receive: vices will not be provided in a natural environment;
• A multidisciplinary assessment of the unique strengths 6. The projected dates for initiation of services and the
and needs of the infant or toddler and the identification anticipated length, duration, and frequency of the
of services appropriate to meet such needs; services;
• Family-directed assessment of the resources, priorities, 7. Identification of the service coordinator from the
and concerns of the family and the identification of the profession most immediately relevant to the infant’s
supports and services necessary to enhance the family’s or toddler’s or family’s needs (or who is otherwise
capacity to meet the developmental needs of the infant qualified to carry out all applicable responsibilities
or toddler; and under this part) who will be responsible for the
implementation of the plan and coordination with
• A written individualized family service plan developed
other agencies and persons, including transition
by a multidisciplinary team, including the parents, as
services; and
required by subsection (e), including a description of the
appropriate transition services for the infant or toddler. 8. Steps to be taken to support the transition of the
toddler with a disability to preschool or other appro-
• Periodic Review: the individualized family service plan priate services.12
shall be evaluated once a year and the family shall be
• Parental Consent: the contents of the individualized
provided a review of the plan at 6-month intervals (or
family service plan shall be fully explained to the par-
more often where appropriate based on infant or toddler
ents and informed written consent from the parents
and family needs).
shall be obtained prior to the provision of EI services
• Promptness After Assessment: the individualized fam- described in such plan. If the parents do not provide
ily service plan shall be developed within a reasonable consent with respect to a particular EI service, then
time after the assessment required by subsection (a)(1) is only the EI services to which consent is obtained shall
be provided.
 Teamwork in Early Intervention 109

All of these aspects of EI are communicated in the IFSP and/or developmental condition, provide information about
process to ensure full participation of the family throughout parent support groups, and help caregivers locate and secure
the program. additional supports, such as respite care.

The Role of Parent Strain in Early

WORKING WITH PARENTS AND Intervention
CAREGIVERS IN EARLY INTERVENTION When very young children experience health and/or
developmental difficulties, parents often experience psycho-
Parent Advocacy in Early Intervention logical strain. When parents are faced with navigating the
complexities of EI systems, they are often compelled to act
Family-centered care in EI is grounded in the belief that as children’s service coordinators and advocates. Extensive
parents are the experts on their own children; therefore, research has outlined the financial strain of having a young
parents are integral in the creation and implementation of child with medical and/or developmental needs, as well as
intervention goals. Service providers are a source of support the time commitment of coordinating EI appointments that
and information for families; ultimately, the purpose of ser- often occur outside of the home.14 Mothers of children with
vice providers in EI is to meet the needs of families. Families disabilities have been found to decrease or leave employment
with children who receive EI services are often bombarded to coordinate their children’s care,15 perpetuating financial
with information, appointments, and varying recommen- difficulties. Parents of children with developmental condi-
dations from doctors and therapists. Within this complex tions experience high levels of stress,16 which is often magni-
system, parents often find themselves acting as advocates for fied by social isolation.17 Given the psychological strain that
their children to receive particular services that match the parents may experience, service providers are in a unique
needs of the family. situation to support not only the development of children
For families of children with special needs, advocacy is but also parent resilience. Research has extensively shown
an empowerment and support process. The use of advocacy that the EI team can support parents to promote positive
here is not necessarily meant to imply a parent’s involvement coping skills and responsive interactions with their children.
in changing complex EI systems. Instead, advocacy is often a As described in the interprofessional approaches to pediatric
dynamic process in which parents strive to understand their care, professionals working with families in EI should be
rights and their child’s rights and to gain as much informa- mindful of the following principles of care:
tion as possible about their child’s diagnosis.13 Through • Service providers must build a trusting relationship
the advocacy process, families can express dissatisfaction with parents. By listening to parent concerns about
and work with service providers within systems to create any aspects of child development and taking time with
change.13 Most parents are involved in advocating for their new families to answer questions, professionals can cre-
own children’s therapeutic, educational, or other accommo- ate a space for parents to express both frustrations and
dation needs.13 accomplishments.
Service providers can support advocacy efforts of parents • EI providers must value parents as the experts of their
of children with developmental conditions. A specific goal own children. By showing that parents are valued in the
of IDEA legislation is to support the capacity of families to process and involving parents in all aspects of care, ser-
meet the special needs of the infants and toddlers.1-3 When vice providers may help support parents to feel increas-
service providers enhance the capacity of families by prepar- ingly efficacious in their parenting role.
ing parents to be advocates for their children, therapists are
meeting a key component of IDEA. EI programs and pro- • The EI team must construct goals with parents; child
viders must promote parent advocacy and parent capacity by goals can address development milestones as well as
helping parents understand their rights, service options for family routines. When families have effective everyday
their children, and options for action in the case that they routines, parents are less stressed and children have
feel appropriate services are not being provided for their more opportunities to practice skills to promote devel-
children.13 opment. Parents should be made aware of this rationale
Service providers in EI systems can promote parent advo- for treatment.
cacy skills by including parents in all aspects of therapy. • All members of the EI team should accommodate fami-
When parents are aware and able to practice the strategies lies’ schedules and roles. For example, if a family has the
that service providers use, they feel more efficacious using goal of promoting a child’s independent eating, service
such strategies in everyday activities. Through a coordinated providers can offer to schedule a family visit during
effort, the EI team can educate parents on the child’s health mealtime. When EI providers embed services in the
110 Section 7

daily-occurring routines of the family (eg, feeding, Four different types of parenting styles include authorita-
napping, driving in the car, changing diapers), they tive, authoritarian, permissive, and uninvolved.21,22 Each
have a greater impact on child development and family style is differentiated by the extent to which a parent shows
routines. demandingness (how firm/domineering a parent is toward
• A parent may gain positive coping skills and decrease the child) and responsiveness (how sensitive/aware a parent is
stress by attending a support group; a service provider toward the child).
may be able to provide information about specific support Research suggests that parenting styles fall along the
groups and respite to families of young children with continuum of demandingness and responsiveness.21,22
medical and/or developmental conditions. The EI team Parents with an authoritative parenting style, featuring high
can encourage parent education and advocacy by shar- demandingness/high responsiveness, provide children with
ing resources. firm direction and encourage freedom for child explora-
tion. Children experiencing this type of parenting style
The EI team should also be aware that children who
tend to be more self-reliant, self-controlled, explorative, and
are younger than 4 with intensive caring needs (eg, young
self-contented. Parents who use an authoritarian parenting
children with health concerns, intellectual disabilities,
style, characterized by high demandingness/low responsive-
mental health issues, and chronic physical conditions) are at
ness, expect child obedience and adhere to absolute values.
increased risk for adverse childhood events (ACEs). ACEs are
Children of authoritarian parents tend to become more
defined as negative and potentially traumatic events that can
discontented, withdrawn, and distrustful. Authoritative or
have detrimental effects on health and well-being.18 These
authoritarian styles have high expectations of their children
experiences range from physical, emotional, or sexual abuse
(high demandingness) but respond differently to their chil-
to parental divorce or the incarceration of a parent or guard-
dren’s abilities (differing degrees of responsiveness). Those
ian. Parents and caregivers who are most likely to perpetrate
with a permissive parenting style have limited demands,
abuse constituting ACEs are those who exhibit the following
allow their children to regulate their own behavior (accept-
characteristics19:
ing whatever the child tends to do), and are very responsive.
• Lack of understanding of children’s needs, child devel- Children with permissive parents tend to become more
opment, and parenting skills; self-reliant, self-controlled, explorative, and self-contented.
• History of child maltreatment in family of origin; Finally, the uninvolved parenting style is characterized by
• Substance abuse and/or mental health issues, including parents who demonstrate low expectations and decreased
depression in the family; responsiveness. The uninvolved parenting style has been
• Young age, low education, single parenthood, large shown to contribute to poor child outcomes, such as child
number of dependent children, and low income; impulsivity, aggression, and decreased social skills.21,22
• Nonbiological, transient caregivers in the home; and The EI team can help families build their parenting skills
through realistic goals based on their children’s strengths
• Thoughts and emotions that tend to support or justify
and current functioning. Parents that are overly focused
maltreatment behaviors. on their children’s deficits may not offer opportunities to
Children’s risks are even greater if their families are practice skills that would build on their children’s existing
socially isolated, disorganized, and stressed and have nega- abilities and strengths. Given that infants need continual
tive family interactions. Finally, ACEs are more common in practice to develop their motor, language, and cognitive
communities prone to violence with concentrated neighbor- skills, the EI team can not only help parents set realistic
hood disadvantage (eg, high poverty, residential instability, goals but also show them how to monitor progress toward
high unemployment rates) and poor social connections.20 achieving their goals. For example, the typical attention
The EI team must work collaboratively to address poten- span of a 1-year-old is only 3 to 5 minutes; a 2-year-old
tial ACEs by developing a plan to address specific existing is only 4 to 10 minutes; and a 3-year-old is only 6 to 15
concerns and risk factors. As a team, they can advocate and minutes. Parents should not expect their child to join them
provide evidence-based resources that are protective for at the movie theater at such a young age but rather plan to
child maltreatment, including connections with commu- watch a movie at home, providing short breaks to engage the
nity-based groups, nurturing parenting skills, encouraging infant in novel activities.
household rules and child monitoring, and facilitating access Pediatric therapists, using their knowledge of health con-
to needed health care and social services. ditions, developmental milestones, therapeutic approaches,
prognostic indicators, and interprofessional collaboration,
Parenting Styles can help families and caretakers gauge their expectations
EI service providers must be mindful of how different for intervention outcomes and promote healthy infant-adult
types of parenting styles can influence a child’s behavior. interactions.
 Teamwork in Early Intervention 111

Promoting Parent Responsiveness and Play imitating the child’s motor actions even if repetitive), the
child is more likely to then imitate an adult.
Play-based activities promote the infant’s developmental For young children, parent responsiveness is vital;
skills and can be consistently provided by responsive par- when parents are more responsive, children show bet-
ents. Pediatric therapists can help parents to incorporate ter language and cognitive outcomes. The EI team can
playful ways of performing functional activities in the home become trained in specific practice models for promot-
and community, offering multiple opportunities to rein- ing parent responsiveness, including, but not limited to,
force needed skills. As earlier stated, parent responsiveness Responsive Teaching24; the Early Start Denver Model25;
is defined as how sensitive and aware parents are toward and Developmental, Individual-Difference, Relationship-
their children, and parents with different styles have varying Based (DIR)/Floortime.26
levels of responsiveness toward their children.23,24 When
parents respond to their children’s cues and interact warmly Supporting Families Transitioning From
with their children, their children show better developmen-
tal outcomes over time.25,26 For example, if a parent talks Early Intervention to School-Age Programs
more to her child during daily routines, the child’s language The young child can transition out of EI services into
and communication are positively impacted. If a parent a preschool program or be directed to other services to
responds warmly to a child’s cries, that child shows better meet her needs before her third birthday. While beginning
social-emotional developmental over time. Service provid- preschool poses challenges for all families, the transition
ers must work with parents to understand how to increase between EI and preschool services is especially challenging
responsiveness to children during daily routines where inter- for parents of children with special needs. EI teams should
actions are most likely to occur. also be aware of common problems that families face,
There are a number of ways that the EI team can pro- including (1) incompatible schedules, (2) conflicting philos-
mote parent responsiveness. Service providers can help ophies between the IFSP and the Individualized Education
parents understand and interpret their children’s cues.25,26 Plan (IEP) that begins at age 3, (3) overlapping/duplicate
For example, a young child with autism spectrum disorder forms, (4) lack of trust/respect for existing assessment infor-
(ASD) may appear disinterested in interacting with a parent; mation, (5) differing eligibility criteria, (6) unclear expecta-
the child may avoid eye contact with the parent or turn his tions/assumptions, (7) different cultures associated with
body away. Service providers can help the parent reframe different agencies/staffs, and (8) loss of funding (eg, waivers,
her interpretation of this behavior. It may be that the young insurance).28
child does not understand how to interact with the parent The EI team should engage in ongoing collaboration to
or does not comprehend the words that the parent is using. discern what the family needs, while advocating for neces-
Instead of thinking that the child does not want to interact, sary services. The EI team should also educate the fam-
service providers can help educate the parent on what the ily about the different regulations that impact services for
child may be expressing when he turns away. infants younger than 3 as compared with those offered to
Another method the EI team can use to promote par- children older than 3. Whereas IDEA Part C for EI is family
ent responsiveness is teaching parents specific strategies focused and mandates family involvement, Part B for early
to engage their children; examples of such evidence-based childhood special education (ECSE) is child centered and
strategies include using children’s interests and promoting focused on education, and the school assumes the responsi-
imitation.27 When a parent follows the child’s lead and/or bility for the child. Because IDEA requires a minimum of 6
uses a child’s interest to engage him in an activity, the child months to prepare families for this transition, it is helpful to
is more engaged. Take the example of the young child with follow some simple guidelines to make the transition from
ASD. A parent is having difficulty engaging in play with the EI to ECSE as easy as possible29:
child, but the parent knows that the child loves trains. The • Allow time to address any questions the family may
parent may sit on the floor and play trains with the child. have about the transition from EI to ECSE.
The parent can imitate the child’s actions with the train,
• Help the family build a relationship with the ECSE pro-
even if the actions seem repetitive, like spinning the wheels
gram their child will attend. Part B of IDEA attempts
of the train. When the parent joins the child in his inter-
to strengthen parental roles in the education process,
est, the child is more likely to socially interact and engage
with the parent. Imitation is a vital component of engaging encouraging patents to be involved in the IEP program
in social interactions with young children; professionals and active in their children’s education at school and
and parents often expect that children should imitate their at home.
actions. When service providers model imitation for a child • Help the family prepare for transition meetings by
(eg, echoing the child’s sounds no matter how functional, encouraging them to visit the preschool and meet with
112 Section 7

the preschool teachers and other staff prior to the transi-

tion meeting.
INTERPROFESSIONAL ACTIVITY
• Educate parents about the differences between IDEA
Part C (EI) and Part B for ECSE. For example, Part C
Developing the Individualized Family
(EI) focuses on the natural environment as compared Service Plan
with Part B (preschool), which focuses on the least As a team, develop an IFSP for one of the case studies
restrictive environment, enabling the child to participate below. Take turns having one person in your group play the
with peers in the learning process as much as possible. role of the parent while others play the roles of professionals
• Encourage families to discuss their expectations, family working with the family.
routines, and concerns about the transition from EI to 1. As a team, how would you describe your role in the EI
ECSE. program to this family?
• Increase parents’ confidence in their children’s ability to 2. Based upon criteria given in the case, is the child
achieve goals in the new setting. eligible for EI?
• Improve parents’ self-confidence in their own ability to 3. What concerns do you think the parent would have
communicate with educational staff and to effectively about the child?
influence the education system. 4. How would you communicate with the family, given
• Connect families with a parent support group, while their situation?
considering child care, transportation, and other family 5. As a team, how would you organize your screening of
barriers that might restrict participation. the child?
As pediatric therapists, we can help parents make the 6. What types of recommendations would you make for
difficult transition that all families face when their children the IFSP in terms of functional goals and parental
enter school; in the case of children with special needs, we involvement?
need to equip them with knowledge, emotional support, and
confidence in their children’s future success.

SUMMARY
Children younger than 3 who are at risk for develop- Case 7-1: A 1-month-old girl diagnosed as
mental conditions and delays can benefit from EI services.
failure to thrive
As outlined in this section, IDEA is a federal mandate
that ensures families and children have access to necessary Lilly was born at 30 weeks’ gestational age. Following
services. Part C of IDEA is most relevant to EI; as part her premature birth, she was placed in the NICU, where she
of this federal mandate, interprofessional teams of service received treatment with oxygen, surfactant, and mechanical
providers serve families of young children with developmen- assistance to help her breathe. Lilly’s birth weight was 1030
tal concerns and conditions. Service providers implement grams. She began feeding, receiving her mother’s breast milk
developmental assessments and screening tools, and each via a gavage tube. Lilly is able to grasp a finger. She can stay
family in EI has an IFSP. There are special considerations awake and alert for short periods. She is now 1 month old.
when working with families of young children with devel- Her height, weight, and head circumference continue to be
opmental conditions; in this section, we discussed parent below the 5th percentile, and her length is below the 10th
advocacy, parent strain, parenting styles, ways to promote percentile. Her mother, Margaret, is a waitress, recently
parent responsiveness, and supporting families from the divorced, who lives in a small, low-income apartment with a
transition between EI and ECSE. By providing services in stairway entrance. Lilly has 2 older brothers, Jeremy (age 2)
natural environments and implementing evidence-based and Phillip (age 3). Margaret’s ex-husband, Paul, a butcher,
practices, interprofessional teams of EI therapists are in a is seeking sole custody of his 2 sons, currently in Margaret’s
unique position to support the daily lives of families of chil- custody. Paul complains that Margaret spends too much
dren with special needs. time caring for Lilly. Margaret wants to prove that she is
capable of caring for Lilly and both of her sons, so she is
seeking support from the interprofessional team serving her
in EI.
 Teamwork in Early Intervention 113

Case 7-2: A 2-month-old boy born with second floor. Narin is now 9 months old and entering EI.
His family is open to suggestions for ways to best manage
spina bifida Narin’s delayed motor development; however, communica-
Jared was born at 35 weeks’ gestational age with myelo- tion with the family during therapy sessions is challenging,
dysplasia (L2 with hydrocephalus and Arnold Chiari type especially when his father is not home. Narin continues to
II syndrome) by Cesarean section. Jared’s diagnosis of a have difficulties with mobility, postural control, fine motor
Chiari II malformation can be made prenatally through control, and language skill; however, he appears to be alert,
ultrasound. Jared had decompressive surgery involving engaged, and eager to learn.
removing the lamina of the first and second cervical ver-
tebrae and part of the occipital bone of the skull to relieve Case 7-4: A 12-month-old girl born with
pressure with shunt placement. He has been in the NICU Trisomy
since his birth, where he is receiving interprofessional care.
Jared is allergic to latex and has difficulty maintaining his Bo was born in Beijing, China, with Trisomy 21 (Down
body temperature. He has difficulty with feeding, requiring syndrome), diagnosed at birth. Born full-term, Bo exhibited
more frequent feeds due to his problems with swallowing generalized hypotonicity, muscle weakness, and hyperflex-
and breathing. Jared’s mother, Sandra, and father, George, ible joints. She also had an unrepaired atrioventricular mal-
live with Alex, their 2-year-old son, in the basement of function and cervical instability.
Sandra’s mother’s home. There are 10 steps into their base- Bo was adopted by her American parents and brought to
ment apartment, which features linoleum floors, concrete the home when Bo was 10 months old. Bo did not receive
walls, and poor lighting. They share a bathroom on the first any therapeutic interventions prior to entering the United
floor of the house. Both parents work low-paying, full-time States. Her parents also have 3 other adopted children,
jobs, and Alex stays with his grandmother during the day. Susan (a 5-year-old daughter from Ecuador), Bill (a 7-year-
Flooding in their neighborhood (and in the basement) has old son from Guatemala), and Rachel (a 9-year-old daughter
led to reduced family income, limiting the family’s resources from Vietnam). Mary and Jake are her adoptive parents.
to cover Jared’s health care costs. Jared is now 3 months old Mary is a housewife who takes care of the children, and
and discharged from the NICU. Jake runs his own business that frequently takes him out of
town. Mary has sought EI services through the pediatrician
Case 7-3: A 9-month-old boy diagnosed with who sees all the other children. Now that Bo is 1 year old,
cerebral palsy Mary is eager to learn about how to help Bo learn needed
functional skills.
Solyna, age 42, and Sopheak, age 57, recently moved
from Cambodia to a small town in the Midwest. Solyna Case 7-5: A 1-year-old girl at risk for
had an uneventful pregnancy and gave premature birth to developmental delays
Narin, her only child. Given the unexpected early birth, the
family was transferred to a large city for Narin’s hospital- Carly was born at 26 weeks’ gestation and spent the first
ization. While the father continued working in the small 9 weeks of her life in the NICU. Carly was on a ventilator
town, his wife remained in the hospital with the newborn. for 2 weeks while her lungs developed, and she had G-tube
Born at 32 weeks’ gestational age, Narin spent his first 3 inserted for feeding for 6 weeks. Carly’s mother, Grace, was
weeks in the NICU, where he was very quiet and did not homeless and became pregnant when she stayed in a home-
cry much. As Narin became physiologically stable, he was less shelter during the winter. Grace was addicted to cocaine
discharged from the NICU and sent home to his rural and was picked up by police a couple of times before Carly’s
hometown. Once at home, both parents became concerned birth. Grace did not receive any prenatal care during her
when they noticed Narin’s shaky movement pattern and his pregnancy, but she went to the hospital to deliver her child
inability to hold his head up or roll by the time he was 6 in a warm environment where she could stay safely off the
months old. The family saw a pediatrician, who diagnosed streets. Based upon her inability to care for the newborn,
Narin with cerebral palsy (mixed type with spasticity and Grace immediately had to give Carly up for adoption. Carly
athetosis) and suggested that the family seek out EI services was placed in foster care but did not receive immediate
for Narin. With the initiation of EI services, both parents care for possible developmental delays. At 8 months, Carly
were relieved and willing to do whatever was best for him. was taken to the local general hospital for a developmental
Although Sopheak is able to communicate in English, he screening. Carly scored below the 25th percentile across all
is sometimes difficult to understand. Solyna has difficulty areas. Referred to pediatric therapists, Carly was further
understanding and speaking English. Narin’s aunt, Raksa assessed using standardized tests and measures and contin-
(also from Cambodia), has since moved into the family’s ued to be below normal for motor activities. While in foster
2-story rental home to assist with Narin’s care. Raksa does care, Carly received EI services with guidance given to her
not understand or speak English. Narin’s bedroom is on the foster mother (Janice) and foster father (Bob). At 12 months
114 Section 7

old, Carly sits independently with support but is unable to 10. Kansas Infant-Toddler Services. At-Risk Infants or Toddlers. Kansas
belly crawl or creep. She is able to bring her hands to mid- Department of Health and Environment Web site. http://www.ksits.
org/download/part_c_manual/ELIGIBILITY.pdf. Published 2013.
line and transfer objects with a weak grasp. She can also Accessed December 5, 2017.
respond to voices by babbling. Her mother has requested to 11. New York State Department of Health. Eligibility requirements.
have Carly returned to her, so the interprofessional team has New York State Department of Health Web site. https://www.health.
been asked to make recommendations for a comprehensive ny.gov/community/infants_children/early_intervention/memoran-
EI program with sufficient supports to aid the mother in da/2005-02/eligibility_criteria.htm. Accessed January 26, 2017.
12. Nachshen J, Jamieson J. Advocacy, stress and quality of life in parents
developing key parenting skills. of children with developmental difficulties. Developmental Disabilities
Bulletin. 2000;28(1):39-55.
Developing a Plan of Care 13. Bailey DB, Bruder MB, Hebbeler K, et al. Recommended outcomes
for families of young children with disabilities. Journal of Early
1. Reflect on the frameworks of practice (Section 2), Intervention. 2006;28:227-251.
cultural competency (Section 3), typical development 14. Seltzer MM, Greenberg JS, Floyd FJ, Pettee Y, Hong J. Life course
(Section 4), and management of care (Section 5). impacts of parenting a child with a disability. Am J Ment Retard.
2001;106(3):265-286.
2. Using interprofessional skills outlined in Section 15. Parish SL, Seltzer MM, Greenberg JS, Floyd F. Economic implica-
1, discuss activities you would teach the family to tions of caregiving at midlife: Comparing parents with and with-
encourage the infant’s participation in each family’s out children who have developmental disabilities. Ment Retard.
daily routine. 2004;42(6):413-426.
16. Estes A, Munson J, Dawson G, Koehler E, Zhou XH, Abbott R.
Parenting stress and psychological functioning among mothers of
preschool children with autism and developmental delay. Autism.
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17. Gupta VB. Comparison of parenting stress in different developmental
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1. US Department of Education. Thirty-five years of progress in edu-
18. Iowa ACEs 360. ACEs impact on brain development. Central Iowa
cating children with disabilities through IDEA. US Department of
ACEs 360 Coalition Web site. http://www.iowaaces360.org/aces-and-
Education Web site. https://www2.ed.gov/about/offices/list/osers/
development.html. Accessed February 2, 2017.
idea35/history/idea-35-history.pdf. Published November 2010.
19. Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of childhood
Accessed January 31, 2017.
abuse and household dysfunction to many of the leading causes of
2. US Department of Education. Part C–Infants and Toddlers with
death in adults: The Adverse Childhood Experiences (ACE) Study. Am
Disabilities. US Department of Education Web site. https://sites.
J Prev Med. 1998;14(4):245-258.
ed.gov/idea/. Published 2017. Accessed December 5, 2017.
20. Sacks S, Murphey D, Moore K. Adverse Childhood Experiences:
3. New York State Department of Health, Bureau of Early Intervention.
National and state-level prevalence. Child trends Web site. http://
Early Intervention Program: Group Developmental Intervention
www.childtrends.org/wp-content/uploads/2014/07/Brief-adverse-
Services Standards. New York State Department of Health Web site.
childhood-experiences_FINAL.pdf. Accessed January 27, 2017.
https://www.health.ny.gov/community/infants_children/early_inter-
21. Baumrind D. Effects of authoritative parental control behavior on
vention/docs/2013_11_grp_dev_inter_serv_standards.pdf. Published
child behavior. Child Dev. 1966;37(4):887-907.
November 2013. Accessed January 27, 2017.
22. Baumrind D. Child care practices anteceding three patterns of pre-
4. Affleck G, Tennen H, Rowe J, Roscher B, Walker L. Effects of formal
school behavior. Genet Psychol Monogr. 1967;75(1):43-88.
support on mothers’ adaptation to the hospital-to-home transition
23. Mahoney G, Perales, F. Wiggers, B, Herman B. Responsive teaching:
of high-risk infants: The benefits and costs of helping. Child Dev.
Early intervention for children with Down syndrome and other dis-
1989;60(2):488-501.
abilities. Down Syndrome Education Web site. https://www.down-
5. Pathways.org. Motor skills. Recognizing early motor delays (ages 0-6
syndrome.org/perspectives/311/. Published 2017. Accessed December
months). Pathways Web site. https://pathways.org/topics-of-develop-
5, 2017.
ment/motor-skills-2/printouts/. Accessed February 13, 2017.
24. Landry SH, Smith KE, Swank PR, Assel MA, Vellet S. Does early
6. Kruer MC. Myoclonic epilepsy beginning in infancy or early
responsive parenting have a special importance for children’s develop-
childhood. Medscape Web site. http://emedicine.medscape.com/
ment or is consistency across early childhood necessary? Dev Psychol.
article/1176055-overview. Published March 14, 2016. Accessed
2001;37(3):387-403
February 13, 2017.
25. Rogers SJ, Dawson G. Early Start Denver Model for Young Children
7. Missouri Department of Health and Senior Services. Guidelines for
With Autism: Promoting Language, Learning, and Engagement. New
vision screening in Missouri schools. Missouri Department of Health
York, NY: Guilford Press; 2010.
and Senior Services Web site. http://health.mo.gov/living/families/
26. Greenspan SI, Wieder S. Engaging Autism: Using the Floortime
schoolhealth/pdf/VisionScreeningGuidelines.pdf. Accessed February
Approach to Help Children Relate, Communicate, and Think. Boston,
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MA: Da Capo Press; 2009.
8. Robins RL, Casagrande K, Barton M, Chen CA, Dumont-Mathieu
27. Zins JE, Elias MJ. Social and emotional learning: Promoting the devel-
T, Fein D. Validation of the Modified Checklist for Autism in
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Toddlers, Revised with follow-up (M-CHAT-R/F). Pediatrics.
28. IFSPweb. Planning for transitions. IFSPweb Web site. http://ifspweb.
2014;133(1):37-45.
org/module3/transition-planning.php. Accessed January 27, 2017.
9. Washington Department of State Health. Nutrition screening for
29. Johnson C. Supporting families in transition between early interven-
infants and children with special needs. Washington Department of
tion and school age programs. Hands and Voices Web site. http://
State Health Web site. http://www.doh.wa.gov/Portals/1/Documents/
www.handsandvoices.org/articles/education/law/transition.html.
Pubs/970-116_NutritionScreeningForInfantsAndYoungCSHCN.pdf.
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Published October 2008. Accessed January 26, 2017.
Section 8
Working With Families of
Young Children With Special Needs
Ketti Johnson Coffelt, OTD, MS, OTR/L and Catherine Rush Thompson, PT, PhD, MS

practices, (3) discuss family and developmental risk factors

OVERVIEW of young children, (4) identify age-appropriate standard-
ized screening and assessment tools for young children and
This section provides an overview of how pediatric thera- families, (5) describe the scope of practice of professionals
pists work with families and other professionals to manage young children in educational and other practice settings,
the special needs of young children. Once children reach the (6) distinguish educational vs medical care for preschoolers,
age of 3, they no longer qualify for early intervention (EI) and (7) describe how to help families transition from EI to
services, as described in Section 7. For those children with early childhood special education (ECSE).
ongoing special needs, this section outlines services avail-
able to preschool children aged 3 to 5 years. Federal and
state laws dictate a different standard of care for children in
the preschool setting from what was provided to families of EARLY INTERVENTION SERVICES FOR
children from birth to age 3. In addition to describing the
changing focus of service provision from family-centered
PRESCHOOLERS
care in natural settings to providing supportive services for
Children aged 3 to 5 years who have special needs may
learning, this section describes risk factors, screening and
qualify to receive free educational services to optimize their
assessment tools, and the roles of other professionals com-
learning. Federal and state laws provide ECSE to those who
monly encountered when working with this population.
qualify through Part B of IDEA.1 IDEA Part B sets the
Finally, it differentiates the provision of educational vs medi-
standards for the achievement of educational goals and helps
cal services. Upon completion of this section, the learner will
families and professionals work collaboratively to address
be able to (1) describe Individuals with Disabilities Education
the individual needs of these children with special needs.
Act (IDEA) components relevant to therapists working with
Children who generally qualify for special education services
preschoolers, (2) discuss recommended interprofessional

Thompson CR. Pediatric Therapy:

An Interprofessional Framework for Practice (pp 115-132).
- 115 - © 2018 SLACK Incorporated.
116 Section 8

are those who received EI services and continue to have the group’s daily routines that further enhance participation
developmental delays. In addition, children with identified and inclusion.
disabilities (eg, cognitive impairments; hearing impair- The concept of family, described as a family-centered
ments, including deafness; speech or language impairments; framework and discussed in the sections on frameworks of
visual impairments, including blindness; emotional distur- practice and EI, continues to be emphasized in ECSE. For
bance; orthopedic impairments; autism; traumatic brain families who have had their children transition from EI
injury; and other health impairments or specific learning to ECSE, opportunities for respectful team participation
disabilities) typically qualify.1 and advocacy skill building should have been ample and
The Division for Early Childhood (DEC) of the Council built upon. IDEA Part C (addressing families of children
for Exceptional Children has developed recommended under age 3) and Part B (addressing children older than 3
practices to provide guidance to practitioners and families years entering preschool) have different foci for care and
about the most effective ways to improve their children’s instruction, so ECSE practitioners need to appreciate these
learning outcomes. These outcomes include promoting the differences, and parents need to be advised of realistic expec-
development of young children, birth through age 5, who tations. Differences in Part C and Part B are outlined in
have or are at risk for developmental delays or disabilities. Table 8-1. Most notably, the shift in focus is from the child
The following recommendations relate to (1) assessment, and family in a natural setting for IDEA Part C to the child
(2) environment, (3) family, (4) instruction, (5) interaction, solely in the preschool setting for IDEA Part B. Although
(6) teaming and collaboration, and (7) transition.2 Many of parents are still actively involved in developing the child’s
these recommendations are highlighted in the previous sec- Individualized Education Program (IEP) as part of the
tion on EI, but several relate more directly to children who team, programs are incorporated into the daily routines in
have transitioned from EI to ECSE and will be highlighted the preschool setting, as opposed to family routines in the
in this section. child’s natural settings, such as the home and community,
In terms of assessment practices, recommendations include as emphasized in EI.
implementing systematic ongoing assessment to identify learn- Instructional practices are the foundation of ECSE, as the
ing targets, plan activities, and monitor the child’s prog- team (including physical therapists, occupational therapists,
ress to revise instruction as needed.2 To achieve this end, speech-language pathologists, teachers, and other services)
assessments need to be sufficiently sensitive to detect each work together to maximize learning and improve develop-
child’s progress; ie, therapists must select tests that are not mental and functional outcomes for young children who
only valid and reliable but also particularly sensitive to have or are at risk for developmental delays or disabilities.
small, incremental changes in measurable behavior. Equally Interprofessional collaboration relies on a variety of inten-
important, practitioners need to report their results to oth- tional and systematic strategies to optimize learning out-
ers in a manner that is both understandable and meaningful comes; otherwise, the child and the family may be confused
for all, especially caregivers, developmental specialists, and by a wide range of inconsistent and disparate information.
teachers. Practices most relevant to ECSE include the following2:
According to the DEC, environmental practices refer to 1. Identifying each child’s strengths, preferences, and inter-
the physical environment (eg, space, equipment, materi- ests to engage the child in active learning;
als), the social environment (eg, interactions with peers, 2. Identifying skills to target for instruction that help a
siblings, family members), and the temporal environ- child become adaptive, competent, socially connected,
ment (eg, sequence and length of routines and activities).2 engaged, and well educated in inclusive environments;
Environmental practice recommendations address both 3. Gathering and using data to inform decisions about
learning and safety to promote each child’s health and devel- individualized instruction;
opment. For ECSE, the DEC recommends providing service
4. Planning for and providing the level of support, accom-
in inclusive, accessible environments during daily routines
modations, and adaptations needed for the child to
that promote each child’s participation.2 Using interprofes-
access, participate, and learn within and across activi-
sional collaboration, team members can modify and adapt
ties and routines;
the physical, social, and temporal environments to promote
access to and participation in learning activities, incorporat- 5. Embedding instruction within and across routines,
ing assistive technology, as appropriate. In addition, environ- activities, and environments to provide contextually
ments should “provide ample opportunities for movement relevant learning opportunities;
and regular physical activity to maintain or improve fitness, 6. Using systematic instructional strategies with fidelity
wellness, and development across domains.”2 This provision to teach skills and to promote child engagement and
can be a challenge in some early childhood settings where learning;
space is limited. Through team collaboration, therapists can 7. Using explicit feedback and consequences to increase
offer suggestions for incorporating active games as part of child engagement, play, and skills. Practitioners use
 Working With Families of Young Children With Special Needs 117

TABLE 8-1
DIFFERENCES BETWEEN THE INDIVIDUALIZED FAMILY SERVICE PLAN AND
INDIVIDUALIZED EDUCATION PROGRAM
FEDERAL LAW IDEA PART C IDEA PART B
Eligibility Children with special needs from Children with special needs aged 3 through 21 years
birth to age 3 years
Focus On the family s and caregivers roles On the child s learning and development
in supporting the child s health,
learning, and development
Program Individualized Family Service Individualized Education Program (IEP)
developed Plan (IFSP)
Outcomes The child and family The child
Environment The environment for learning is in Environments focus on the preschool (eg, classroom,
the natural environment (often the playground, dining area), incorporating assistive
home, child care, or the community) technology, if needed; social interactions with other
children are encouraged
Coordination EI service manager or case worker Local school districts are authorized to coordinate and
coordinates services integrated manage the child s services
by the IFSP; services may involve
many agencies in providing services
because of the child s age
Meeting with Offer information and resources and Called to develop long-term and short-term goals for
family to define the various agencies roles the child, accommodations and modifications,
and financial responsibilities services, and child placement
Frequency of Typically every 6 months Typically annually (those that involve the family)
formal meetings
Adapted from PACER Center. What is the difference between an IFSP and an IEP? PACER Center Web site. https://www.pacer.org/parent/
php/PHP-c59.pdf. Pubished 2011. Accessed December 11, 2017.

peer-mediated interventions to teach skills and to DEC also provides helpful recommendations for interac-
promote child engagement and learning; tion practices that mirror those discussed in the section on
8. Using functional assessment and related prevention, pro- cultural competency. The following DEC recommendations
motion, and intervention strategies across environments are designed to facilitate interactions that promote specific
to prevent and address challenging behavior learning outcomes for each child 2:
9. Implementing the frequency, intensity, and duration 1. Observing, interpreting, and responding contingently to
of instruction needed to address the child’s learning the range of the child’s emotional expressions;
needs; 2. Encouraging the child to initiate or sustain positive inter-
10. Using and adapting specific instructional strategies that actions with other children and adults during routines
are effective for dual language learners when teaching and activities through modeling, teaching, feedback,
English to children with disabilities; and or other types of guided support;
11. Using coaching or consultation strategies with others to 3. Providing natural consequences for the child’s verbal and
facilitate positive adult-child interactions and instruc- nonverbal communication and by using language to
tion intentionally designed to promote child learning label and expand on the child’s requests, needs, prefer-
and development. ences, or interests.
Additionally, recognizing the importance of cultural 4. Observing, interpreting, and responding intentionally
competency and the need to be sensitive and responsive, the to the child’s exploration, play, and social activity by
118 Section 8

joining in and expanding on the child’s focus, actions, of the environment? The family unit is at risk due to the
and intent; and unique demands placed upon them.
5. Observing, interpreting, and “scaffolding” in response to As the child enters preschool education, the family unit
the child’s growing level of autonomy and self-regulation. is vulnerable to a new set of professionals from the educa-
The idea of scaffolding is to provide assistance just tional realm, who are ready to share their knowledge and
slightly beyond the child’s learning abilities, helping expertise. Professionals must guard against overloading
him build upon his existing abilities.3 This is the the family with “homework” that can be overtaxing. For
primary strategy therapists can help teachers learn in example, expecting family members to therapeutically feed
respect to knowing the child’s level of competence in and position their child for every meal is not realistic and
performing motor, language, and cognitive skills. too demanding. Given that the overall goal is to support the
A cornerstone of successful ECSE programs is using effec- learning and development of the child, practitioners need be
tive teaming and collaboration practices, as discussed in earlier nonjudgmental, allowing time for trust and relationships to
sections. The DEC’s recommendations for these practices develop to reassure vulnerable families.
are similar to those identified by organizations supporting All members of ECSE teams must pay close attention
interprofessional care; they recommend building relation- to how a child is learning, looking for potential signs of
ships through respect, support, capacity enhancement, and hearing, vision, and developmental problems. Common
cultural sensitivity. In addition to principles stated earlier in risk factors for all children aged 3 to 5 include develop-
this book, it elaborates on assisting each other to discover ing ear and eye infections that impact their sensorimotor
and access community-based services and other informal skills, play, social interactions, and knowledge development.
and formal resources to meet family-identified child or fam- Observations of children at play and while interacting with
ily needs. Oftentimes, families and teachers seek out enrich- peers may provide valuable information for identifying those
ment opportunities in the community, and therapists can children who may be at risk. Carefully following a child’s
provide appropriate options. With these practices in mind, development across areas of preacademic skills, motor skills,
pediatric therapists play an important role in anticipating sensory exploration, social/play interactions, communica-
family and developmental risk factors during these early tion skills, social behaviors, and self-care routines offers
childhood years (Table 8-2) . specific clues as to her need for further assessment by specific
disciplines or the entire preschool educational team.
Specific communication, social interaction, and behavior
FAMILY AND DEVELOPMENTAL problems may require observations of the child in a variety
of contexts. These initial observations of her play skills,
RISK FACTORS social skill development, and ability to follow daily routine
tasks are the first steps in documenting the need for further
Any change to a family’s routine can be stressful and pose evaluation for a child with suspected autism spectrum dis-
unique risks. While prioritizing the educational and devel- order (ASD).
opmental needs of the child in the preschool, it is important • What is motivating to the child or of interest to her?
to appreciate the family’s culture, routines, and environment • What types of behaviors interfere with play and preaca-
to ease the transition from EI to ECSE. In addition to the demic learning?
developmental risk factors described in Section 7, there are • How does the child play with toys?
additional considerations for a child older than 3. What are
• How does the child communicate with others?
the parents’ desires for their child? What supports or limita-
tions from the home setting may impact the child’s skills The following questions can guide a practitioner to
and routines as they transition to a preschool classroom? attend to behaviors for child who may have significant atten-
This is an opportunity for team members to collaborate with tion problems that many times are diagnosed as attention
each other as they gather information from the family per- deficit hyperactivity disorder (ADHD)4:
tinent to their perspective disciplines. While planning care, • Does the child reportedly need constant attention and
pediatric therapists need to be thoughtful and respectful of not play alone at home?
the parents’ time by reducing redundancy in the types of • Do parents report that the child has problems wind-
questions asked about their child. ing down at the end of the day, popping out of bed
Risk factors for the child are likely to align with the repeatedly?
nature and severity of the child’s exceptionality. Is the child’s • Is the child able to sustain attention (normal attention
condition progressive in nature? Is there an unusual demand span for a 3-year-old is 7 to 9 minutes)?
for child caretaking? How dependent is the child upon oth- • Is the child destructive with toys?
ers for her daily care, communication, and play exploration
 Working With Families of Young Children With Special Needs 119

TABLE 8-2
DEVELOPMENTAL OBSERVATIONS FOR CHILDREN AT RISK
LEARNING COMMON OBSERVATIONS OR RISK FACTORS
AREAS
Preacademics • Does the child initiate and complete task independently?
• Is the child able to hold attention to complete task?
• Is the child easily distracted?
• Does the child play make-believe games?
• Does the child remember parts of a story?
• Is the child interested in knowing colors, ABCs, numbers?
• Does the child use central or peripheral vision to perform tasks?
Motor skills • Does the child sit using a slumped posture?
• Is the child able to maintain head in erect position during play?
• Does the child lean into furniture or consistently lay down during play?
• Is the child able to maintain balance while using hands?
• Does the child run easily?
• Does the child climb on playground equipment?
• Does the child only play on one piece of playground equipment (eg, only being
pushed on a swing)?
• Does the child use both hands together while manipulating items?
• Does the child use one hand predominately, with the other by her side?
• Is the child able to pick up small items?
• Does the child drop items?
• Does the child have hand strength to hold items?
Sensory • Does the child prefer solitary play?
exploration • Does the child prefer to be moving or active?
• Does the child bump into furniture or others during play or transitions?
• Is the child able to touch various textures during play (eg, water, paint, glue)?
• Does the child have difficulty grading pressure while holding items (too much or
too little)?
• Does the child seek movement by rocking, spinning, or jumping?
• Does the child repeat words or self-vocalize?
• Does the child excessively look at, touch, mouth, or smell objects?
Social/play • Does the child separate from his parents?
interactions • Does the child play alone or in isolation?
• Is the child interested in playing with others?
• Is the child only interested in preferred toys?
• Does the child play with others, or beside them?
• Does the child move away from others during play?
• Does the child take turns?
(continued)
120 Section 8

TABLE 8-2 (CONTINUED)

DEVELOPMENTAL OBSERVATIONS FOR CHILDREN AT RISK
LEARNING COMMON OBSERVATIONS OR RISK FACTORS
AREAS
Communication • Does the child make eye contact with others?
skills • Does the child smile, laugh, express feelings?
• Does the child communicate using words?
• Does the child understand 2- to 3-step directions?
• Does the child express wants and needs using words?
• Will the child approach others?
Self-care • Is the child independent in toileting?
routines • Does the child need repeated prompts to finish a learned task?
• Does the child use both hands to pull up and down pants?
• Does the child manage clothing items, knowing which items belong to her?
• Is the child able to manipulate fasteners?
• Does the child use a spoon to scoop items?
Social behaviors • Is the child able to organize behavior response to the situation?
• Do specific tasks or environments calm or arouse the child?
• Does the child pick up on social and environmental cues?
• Does the child demonstrate restricted interests or repetitive behaviors?

• Does the child have difficulty playing with other chil- or provide care to the child or play a peripheral role within
dren, with a higher incidence of biting, kicking others, the child’s social environment. Typical indicators of child
or pushing peers? The child should be able to engage in neglect include lack of supervision, adequate clothing and
cooperative play and display kindness and caring. hygiene, medical and dental care, adequate nutrition, and
• Is the child overly active, appear clumsy, and have a shelter. As practitioners, there is a sensitivity to identifying
higher incidence of falling or accidents? neglect based on family cultural values and expectations
and differing child rearing practices. A family living with
• Does the child yell or overreact to everyday situations?
poverty is not an indicator of child neglect.
By age 3 to 4 years, a child should be able to tolerate
As mentioned in Section 7, types of child abuse include
changes in routines.
physical, sexual, and emotional trauma. Signs of physical
Communication among the preschool team members abuse of a young child could include any or all of the fol-
is crucial because each discipline may have similarities and lowing: bruises, burns, lacerations and abrasions, skeletal
differences in terminology associated with ASD or ADHD injuries, and head and internal injuries. A child experiencing
during the initial phases of observation of children who may emotional abuse may show signs of being overly compliant
be at risk. and passive. Conversely, the child could display extremely
All children at this age typically become more mobile aggressive, demanding, and rage-like behaviors.
both inside and outside as they explore their expand- A child who has been abused most often will display a
ing environment. As children explore and learn from the lag in development when compared with same-age peers,
interactions with objects in the environment, they are at particularly in the area of self-care. The child may exhibit
a potential risk for falls, burns, poisoning, getting hit by a a lack of curiosity and enjoyment, display self-stimulating
car, accidental drowning, or accidental gunshot. All adult behaviors, and have a fear of physical contact from others.
caregivers and providers of the child are responsible for their The child may revert to an earlier developmental state. For
safety and teaching them basic safety rules. example, a 5-year-old who was previously toilet trained
All children at this age are at risk for suspected neglect or might begin to wet herself. Sometimes the child will act
abuse from adults with whom they come into contact with out sexual or abusive scenarios with toys or objects without
due to their helplessness. The adults could be familial and/ ever vocalizing the signs of abuse. Certain parent groups
 Working With Families of Young Children With Special Needs 121

are more susceptible and at risk for possible child neglect the child’s strengths and needs, with an emphasis on the
or abuse, specifically parents with disabilities themselves child’s performance in preacademic and nonacademic skills
and adults with drug and alcohol addictions. Our role and and routines. Table 8-3 lists commonly used assessments for
responsibility is to find assistance and resources for these ECSE.
parental groups. We are required to respect family and cul- ECSE teams (including physical therapists, speech-
tural differences and provide alternatives and education for language pathologists, and occupational therapists) involve
enhancing their parenting skills. bottom-up and top-down approaches, incorporating obser-
The law stipulates that any person (medical, educational, vations within preschool environments (eg, playground,
or otherwise) who has definite contact with the child and classroom, hallway, gym, library, art room, bathroom),
suspects abuse is a mandated reporter. If there is reasonable appropriate discipline-specific evaluation measures, data
cause to suspect neglect and/or abuse of a child, practitioners collection, and identification of student goals. Researchers
are instructed by law to contact and report the issue to a state have identified the following essential components for team
department of social services. To report any suspected child members to consider when collaborating in the development
abuse, contact the Childhelp National Child Abuse Hotline and implementation of an integrated educational program6:
at 1-800-4-A-CHILD (1-800-422-4453). To report child • Goals belong to the learner and not individual team
sexual abuse, call 1-888-PREVENT (1-888-773-8368). members.
• Team members need to contribute needed informa-
tion and skills to enhance achievement of all goals and
SCREENING AND ASSESSMENT TOOLS objectives.
• Professionals provide unique perspectives through their
As stated by IDEA of 2004,1,2 no single measure or respective disciplinary methods and skills.
assessment tool should be used as sole criteria for deter-
• Interprofessional collaboration addresses the child’s
mining an IEP for a child. The evaluation should “use a
needs more successfully in a wider variety of contexts.
variety of assessment tools and strategies to gather relevant
functional, developmental, and academic data including • Effective integration involves focusing on meaningful
information provided by parent.”6 Special education pre- activities to the learner.
school teams are required to consider information from the ECSE programs are designed to meet the individualized
multiple sources, including the family and medical and ser- needs of each child and are generally available in most school
vice provider reports, but are not bound by any recommen- districts. Parents who suspect their young child may have a
dations or decisions offered by medical teams. This is true developmental delay or disabling condition that may affect
for children with the medical diagnosis of ASD or ADHD their child’s learning can contact their local school district to
because there is no automatic eligibility guarantee for special make a referral for an ECSE evaluation. Children with mild,
education or related services under IDEA. moderate, and severe deficits typically qualify for education-
A referral for evaluation under IDEA Part B (covering related services provided in local preschools.
preschoolers and school-aged children) must follow fed- In contrast, children needing medical attention must go
eral law and regulations and individual state regulations to a clinic or hospital for an evaluation and/or treatment by a
and comply with individual service provider practice acts. medical professional, which is oftentimes costly to the fam-
Informed written consent must be obtained from a parent ily in terms of time, energy, and money. Medical profession-
before evaluations are conducted by the preschool educa- als perform discipline-specific, age-appropriate, standard-
tional team. Under IDEA Part B, a request for an initial ized assessments, clinical examinations, and observations to
evaluation may come from a parent, state agency, or local select interventions to promote the best health outcomes for
educational agency (LEA). the child. In the medical model, parents are typically held
Oftentimes in the preschool environment, assessment responsible for locating and paying for the needed thera-
information is gathered from adults in the child’s environ- peutic services. Health insurance may assist with payment,
ment, from the teaching staff, and from parents or care- but not always. Table 8-4 lists the distinctions between the
givers. Self-report measures, interviews, and observations educational vs the medical model of care commonly applied
should be considered by service providers as providing infor- to young children and their families.
mation about how the child performs and communicates in Some children with special needs may receive therapy
the context of the task and situation. in both educational and medical settings, depending upon
Discipline-specific evaluation tools used by service pro- their health condition, because educational goals may not
viders are conducted to determine eligibility for special edu- fully address the medical needs of children with certain
cation instructional and related services. In most preschool diagnoses. For example, a child with Down syndrome may
cases, the evaluation process culminates in identification of be engaged in preschool learning activities to develop motor,
language, and cognitive skills but may also be monitored in
122 Section 8

TABLE 8-3
FORMAL AND INFORMAL TYPES OF EARLY CHILDHOOD ASSESSMENT (3 TO 5 YEARS)
FORMAL DESCRIPTION EXAMPLES
ASSESSMENTS
Norm- Compares child s performance • Peabody Developmental Motor Scales (Second Edition)
referenced to a normative group of pre- • Miller Function & Participation Scale (M-FUN)
assessment school children • Bruininks-Oseretsky Test of Motor Proficiency
(Second Edition)
• Assessment of Motor and Process Skills (AMPS)
• School Assessment of Motor and Process Skills
(School AMPS)
• Motor Free Visual Perception Test (Third Edition)
• Beery-Buktenica Developmental Test of Motor
Integration (Sixth Edition)
Criterion- Indicates child s performance • Hawaii Early Learning Profile (HELP)
referenced based on a set of criteria • School Function Assessment (SFA) K-6
assessment • Gross Motor Function Measure (GMFM)
• Knox Preschool Play Scale
• Child Sensory Profile-2
• Developmental Assessment for Individuals with
Severe Disabilities (DASH-3)
• Wee-FIM II
• Pediatric Evaluation of Disability Inventory (PEDI)
INFORMAL DESCRIPTION EXAMPLES
ASSESSMENTS
Self-report Questionnaires completed by • Pediatric Evaluation of Disability Inventory (PEDI)
measures parent or teacher using scales
and checklists of behaviors
and skills
Interview Structured and semi-structured • Clinical interview with parents and
interview to gather and review observation of child
pertinent information • Interviews with parent and teacher and observation of
child in class or within school context
Observations/ Authentic and ecologically • Observations within classroom, bathroom, outside,
semi-structured based observations of child s snack time, arrival and dismissal
checklists skills and performance in • Preschool educational checklist
context, activity, interaction • Self-care checklist
• Reflex integration/righting and equilibrium reactions
• Range of motion/strength/muscle tone/posture
• Sensory system observations
• Social-emotional observations
• Cognitive/perceptual/body awareness observations
Review of Respond to initial referral by Practitioners in medical setting discuss orders with
medical records reviewing medical reports other providers
 Working With Families of Young Children With Special Needs 123

TABLE 8-4
EDUCATIONAL VERSUS MEDICAL MODELS
CRITERIA EDUCATIONAL MEDICAL
Team IEP team (including child, family, Health care professionals
and educational staff)
Payment Federal and state funds Insurance/Medicaid with payment by the family
support services
Focus Student learning and safety; Therapy addresses medical conditions and aims to
adaptations and interventions improve health, fitness, and wellness
to allow the student to
participate, access special
education and the
school environment
Location School (classroom, hallways, Acute hospital, subacute hospital, and rehabilitation
lunchroom, playground); setting (inpatient clinic, outpatient clinic, homebound);
includes transportation and home programs are commonly given to the family
home-based education, following the child s hospitalization
if needed
Eligibility Determined by IDEA Part B Determined by health needs appraised by physician or
criteria measured by the other health professional
preschool team
Delivery Services may include inclusive Services typically involve direct one-on-one interventions
direct, indirect, or consultative to achieve prescribed goals
services, collaborating with
the IEP team for
program development
and implementation
Documentation Jargon-free reports for use by Discipline-specific reports that meet professional
family members, IEP team, and standards and reimbursement criteria
related school staff
Example: This is a temporary medical This injury would get immediate attention in an acute
Child with a condition that is not covered care hospital. After the immediate repair and casting of
fractured femur by IDEA Part B or C. This child the femur, the child would receive instruction in gait
would not qualify for physical training and wheelchair mobility, followed by outpatient
therapy services in a school care to regain strength and endurance for walking
setting as long as the child had
access to a wheelchair
and/or crutches to move
between classes
124 Section 8

an outpatient clinic for leukemia. Ideally, professionals com- Scope of Practice in Various Settings
municate across practice settings to coordinate information
sharing with families and to optimize care for children with The scope of therapeutic practice varies with practice
special needs. setting because the focus of care is different. Table 8-5 gives
examples of the scope of practice and types of service pro-
vided to children (3 to 5 years) by physical therapy, speech-
language therapy, and occupational therapy in preschool vs
SCOPE OF PRACTICE FOR other settings.
PROFESSIONALS WORKING WITH Interprofessional behaviors are key to success within and
across practice settings. Collaboration and discussion among
CHILDREN 3 TO 5 YEARS service providers and key stakeholders (eg, parents, teachers,
caretakers, and other family members) promotes seamless
Preschool Setting care and achieves desired outcomes. Although each profes-
sional may provide separate services, the interprofessional
Preschool education programs provide the social context team values frequent communication to coordinate services
for knowledge development of preschool-aged children. The and best address the changing needs of the child, family, and
aim of preschool education is to deliver safe and quality care, teaching staff. Team model approaches offer comprehensive
preparing the child for the role of student. Therapists may joint planning and decision making.
play an important role in screening children in preschools to Becoming an effective team member takes effort through
assess their developmental skills. Children with disabilities active listening and reflection in communication practices
can receive unique and individualized educational program- within and between the child’s medical and educational
ming from the preschool IEP team, as described early in team. As practitioners, it is important to know the role and
this section. Collaborative relationships develop among the responsibility for each scope of practice area and to appreci-
preschool team (typically comprising the parent, teacher, ate the similarities and difference between service providers.
psychologist, principal, speech-language pathologist, occu- Through this understanding and awareness, team members
pational therapist, and physical therapist). These educa- generate plans and actions contributing to the overall learn-
tional teams identify the strengths and needs of the child ing and development of the child. For example, a preschool
using dynamic evaluation approaches to develop appropri- team (comprising a teacher, physical therapist, occupational
ate educational goals and objectives for the child’s learning therapist, and speech-language pathologist) is presented with
and success in the preschool environment. Successful team the situation of a preschool child with ASD who has limited
interaction is essential for effective intervention services for interaction with playground equipment and peers during
the child with special needs.7 outdoor recess time. This limited interaction can negatively
impact the child’s psychosocial and physical development.
Medical Setting Each team member can contribute to a team solution for
A preschool-aged child may be referred to or seen within this child’s recess, using the knowledge and skills from her
a medical setting for a multitude of reasons based on a respective practice area (Table 8-6).
medical illness or injury. The physical therapist, occupa- Often, physical therapists, occupational therapists, and
tional therapist, and speech-language pathologist assess the speech-language pathologists working in educational set-
child’s needs from their respective scopes of practice and tings travel to multiple building sites, delivering services to
provide evidence-based interventions, along with home a wide range of school-aged children. Given that pediatric
programming instructions for parents or caregivers. Family- therapists may not be on site for daily consultation and pro-
centered care is widely accepted by hospital and pediatric gram implementation, they must engage in frequent check-
rehabilitation teams for the child and family. Team meetings ins and facilitate the transfer of training and information
are quickly established for the care of the child and to ensure between team members for continuity of care.
that the family becomes familiar with therapy services for
contributions to team decision making. Each discipline
brings its respective knowledge of age-appropriate develop- REFERRALS
mental skills. Fostering the child’s normalcy is a team goal
in this environment, so therapists encourage the child to When a young child demonstrates developmental, learn-
resume activity as soon as possible, performing their daily ing, or behavioral difficulties, the child is closely observed
tasks and interacting with others. Promoting play and daily by the teacher, who documents the child’s behavior. These
routines may help the child cope and manage his inpatient issues are brought to the interprofessional team for discus-
or outpatient experience. sion with the goal of developing and implementing strat-
egies toward resolution of these difficulties. Although
 Working With Families of Young Children With Special Needs 125

TABLE 8-5
PROFESSIONALS’ THERAPEUTIC SCOPE OF PRACTICE IN EDUCATIONAL AND OTHER SETTINGS
SERVICES FUNCTION OF PROVIDER IN FUNCTION OF PROVIDER IN
PRESCHOOL SETTING MEDICAL/COMMUNITY SETTING
Focus • Learning through play-based and • Return to health through
educational activities therapeutic and age-appropriate
means, including play
Interprofessional • Education to team and family • Education to team and family
• Assessment and management of learning • Evaluation and management of
activities impacted by disabilities acute medical conditions
Physical therapy • Assessing and addressing factors that impact • Assessing and addressing
learning and movement (eg, memory, impairments that impact daily
attention, postural control, mobility, transfers, function, including postural control
gross motor skills, pain, breathing, strength, and movement (eg, musculoskeletal,
speed, endurance, balance, coordination, cardiopulmonary, respiratory,
functional skills, play activities, and integumentary, genitourinary,
interpersonal skills gastrointestinal, and other
• Interventions include training and body systems)
environmental adaptations (eg, equipment, • Interventions include management
assistive devices, wheelchair seating, safety, of body systems (eg, pain and burn
risk reduction) management) and training in
functional skills
Speech- • Articulation • Augmentative and alternative
language • Language communication
therapy • Social communication • Play and social interaction
• Play • Communication
• Augmentative communication • Feeding and swallowing
• Oral motor and swallowing • Learning and cognition
• Learning and cognition
Occupational • Play and learning • Learning and behaviors
therapy • Functional motor skills (eg, self-help, eating, • Functional daily tasks (eg,
managing personal items, toileting) toileting, grooming, dressing,
• Preacademics (eg, hand skills, prewriting, bathing, transfers)
visual perceptual skills) • Play and motor skills (fine and gross)
• Social participation • Feeding and swallowing
• Sensorimotor skills • Assistive technology devices
• Behavior regulation skills • Adaptations/modifications to task
• Feeding and oral motor skills and environment
• Adaptive equipment/positioning
• Assistive devices
126 Section 8

TABLE 8-6
EXAMPLES OF SHARED PLANNING AND RECESS INTERVENTIONS FOR CHILD WITH AUTISM
PRESCHOOL TEAM UNIFIED TEAM INTERVENTIONS DISCIPLINE SPECIFIC
MEMBERS INTERVENTIONS
• Physical therapist • Use of group play skills to increase gross • Multisensory activities
• Speech-language motor skills on playground equipment • Motor imitation training
pathologist • Visual supports to increase social initiation • Physical exercise routines or
• Occupational and group play at recess movement activities
therapist • Use of social stories to improve social skills • Peer training with model with
• Early childhood during recess specific playground equipment
special education • Adult support to assist with turn-taking and • Social stories/narratives
teacher group play with playground equipment • Joint attention training
• Adult modeling and prompting during • Natural behavioral
recess play interventions; occurs in context
• Use of special interests/
personal motivation

interprofessional team members can develop appropriate therapy service team and the family to ensure that all parties
plans for helping the child with these difficulties, some understand service options and projected costs to coordinate
problems may fall outside of their scope of practice and therapeutic care.
require referral to other experts. Table 8-7 lists common In terms of reimbursement, IDEA Part B funds the edu-
referrals made for preschool children with special needs. cation of children with disabilities, offered as free and appro-
priate public education (FAPE). Pediatric therapists should
become familiar with federal and individual state laws and
REIMBURSEMENT regulations that define the standards that qualify a pre-
schooler with a disability for these free services. According
Within the medical setting, inpatient and outpatient to IDEA Part B, speech-language services are considered
services are funded by various sources, including a combina- part of special education services and are offered for children
tion of private insurance carriers, Medicaid, state-funded with problems with communication and language. Similarly,
programs, and/or Medicare. Local insurance companies physical therapy and occupational therapy are offered to
may have different requirements for therapeutic services, children with disabilities but are considered related services.
equipment, and assistive devices. Each state has Medicaid Under IDEA 2004, ECSE eligibility is cross-categorical.
protocols and regulations related to funding of therapeutic This means that preschool children with disabilities can
services. Medicare guidelines are more widespread across the present with a wide range of functional and ability levels and
United States. Care for young children can be cost prohibi- receive educational and related services. Examples of ability
tive, and team members should always be mindful of fami- levels could include a child who has developmental delays in
lies’ limited financial resources and regulations dictating one or more of the following areas: fine motor skills, gross
reimbursement for care. motor skills, communication and language skills, social-
Coordination of care is essential for reducing confusion emotional skills, and cognitive skills. A child could present
for families. Service providers need to share the various con- with a more global developmental delay, such as ASD, or
cerns of families, including, but not limited to, (1) services display mild to severe forms of neurological or musculoskel-
provided, including type, intensity, frequency, and duration; etal disorders. These children with disabilities all qualify
(2) cost of services; (3) expected outcomes; (4) short-term for free educational services tailored to their needs by the
and long-term goals; (5) the family’s role in care; and (6) interprofessional team and outlined in the IEP.
plans for when the child is ready to transition to other set-
tings. It is recommended that a case manager work with the
 Working With Families of Young Children With Special Needs 127

TABLE 8-7
EXAMPLES OF SHARED PLANNING AND RECESS INTERVENTIONS FOR CHILD WITH AUTISM
PROFESSIONAL FORMAL EDUCATION/TRAINING EXPERTISE
Certified orthotist Nationally board certified: formal education in Designing custom devices,
biomechanics and material sciences custom-fit orthosis (eg,
supramalleolar orthosis, ankle-foot
orthosis, knee-ankle-foot orthosis)
Ophthalmologist Nationally board certified medical doctors: Diagnosing, managing, and
completed residency in ophthalmology treating medical conditions that
cause visual impairments
Feeding and swallow- Advanced certified training: continuing Managing eating and
ing specialist education and training for competence in swallowing problems based upon
assessment and intervention of dysphagia their advanced knowledge of
normal and abnormal oral reflexes,
swallowing phases, and instrumental
assessments (eg, video fluoroscopy
and fiber optic endoscopy)
Optometrist Nationally board certified: doctor of optometry Providing primary eye care and
diagnosing and treating medical
conditions causing vision loss
Wheelchair seating Rehabilitation Engineering and Assistive Performing equipment evaluations
specialist/assistive Technology of North America (RESNA) and customizing and fabricating
technology provider Certification: completed training for equipment based upon their
customizing positioning equipment and/or knowledge of medical necessity
assistive devices

The Children Action Network (CAN), as part of the

ADVOCACY DEC of the Council for Exceptional Children, works to
shape policy by providing feedback on current and upcom-
For successful programming, all service providers should ing legislation, regulations, and funding.8 Nationally, the
be advocates for parents/caregivers and children with special DEC works with other organizations such as the National
needs. As discussed in earlier sections of this book, pediatric Association for the Education of Young Children (NAEYC)
therapists working with young children must respect family to promote developmentally appropriate practice and pro-
differences and help families cope and develop effective par- vide guidance on inclusion. According to CAN:
enting strategies. Furthermore, the interprofessional team
can help families develop their advocacy skills by provid- Professionals working with young children with dis-
ing information about their children’s physical and mental abilities and children at risk for developmental delays
health conditions and learning needs and by offering sug- hold a unique perspective. It is imperative that they
gestions for medical equipment, assistive technology, adap- share their experiences with policy makers…stay-
tive devices, and intervention programming to supplement ing informed about key issues through newsletters
services received during school. Therapists’ responsibilities and email alerts, building and maintaining relation-
include finding appropriate local, regional, and national ships with policy makers, and sharing perspectives
resources for the parent to become further informed. through phone calls, emails, personal visits with
In addition, it is important to recognize the valuable elected officials.9
information that families can share with the interprofes- Pediatricians, EI providers, special educators, and pro-
sional team. Families know their children best and can grams serving individuals with developmental disabilities
share valuable insights from their personal experiences, their can strengthen advocacy efforts by aligning efforts with
unique knowledge, and their successes with their children. partners such as Head Start and the Women, Infant,
128 Section 8

Children (WIC) Program. Advocacy backed by research of and a series of fact sheets on milestones and developmental
evidence-based practice will help to educate those responsi- and behavioral delays. These materials can be downloaded
ble for developing policy and providing needed support. The from the website or ordered in bulk.
DEC supports ongoing research efforts related to the indi- Additional websites that can support healthy growth and
vidual and unique needs of young children with and at risk development of young children include the following:
for disabilities and their families in early childhood settings. • BAM! Body and Mind (https://www.cdc.gov/bam/
index.html). “This website, developed by the Centers
for Disease Control, provides child- and youth-friendly
TRANSITIONING FROM EARLY information about disease, food and nutrition, physical
activity, and safety as it relates to a young person’s life
CHILDHOOD SPECIAL EDUCATION TO and body.”
KINDERGARTEN PROGRAMS • The National Dissemination Center for Children with
Disabilities (NICHCY) (https://www.nidcd.nih.gov/
Finally, the DEC recommends transition practices that directory/national-dissemination-center-children-dis-
facilitate the move from one setting to another. Just as abilities-nichcy) provides information to parents, com-
infants transition into ECSE from EI, young children with munities, educators and the general public on specific
special needs graduate from preschool to enter kindergarten disabilities; programs and services for infants, children
or school-age programs. Not only do parents of children with and youth; U.S. special education law; and effective
significant disabilities share common concerns with other educational practices. NICHCY also offers links to
families for young children entering a new school, they also state agencies, parent groups and organizations around
worry about losing their strong support systems and wonder the country that offer assistance and information.”
how, when, where, and by whom their child’s special services • Born Learning Campaign (www.bornlearning.org).
will be provided.10 Thus, entrance into school for children “The United Way of America, partnering with the Ad
with disabilities can be exceedingly complex and anxiety Council and Civitas, created a website that helps par-
laden for families.10 Prior to the transition to elementary ents, caregivers, and communities create high-quality
school, the ECSE team must identify developmental and early learning opportunities using everyday events for
family risk factors to ensure that concerns are addressed young children. The website provides comprehensive
in the child’s educational programs, appropriate referrals, developmental information on children from birth to
and consultation. Throughout the transition process, ECSE 5 years of age.”
practitioners should support the adjustment of the child
• Pacer Center: Parent Advocacy Coalition for
and family by exchanging information between settings
Educational Rights (www.pacer.org). “The center was
before, during, and after transitions, as well as incorporat-
created by parents with children with disabilities to
ing planned strategies to support the adjustment.10 Table
help other parents with similar experiences. The site
8-8 lists helpful steps in the collaborative transition process.
offers a wealth of resources, including associated links,
newsletters, and publications on issues related to special
education and disability.”
RESOURCES FOR EARLY CHILDHOOD • AblePlay (www.ableplay.org). “Developed by the
SPECIAL EDUCATION National Lekotek Center, AblePlay TM is a toy rat-
ing system and website that provides comprehensive
Many resources are available to help young children with information on toys for children with special needs, so
disabilities. The Centers for Disease Control and Prevention parents, special educators, therapists, and others can
(CDC) and the National Center on Birth Defects and make the best choices. Toys are categorized according
Developmental Disabilities have produced a toolkit to help to disability and age group.”
parents learn about the milestones in their children’s growth • CanChild Centre for Childhood Disability Research
from birth to age 5, as well as developmental delays and (www.canchild.ca). “The focus of this organization is
other disabilities. The Learn the Signs. Act Early. campaign to support research on children and youth with disabili-
and Toolkit for Parents on Early Development (www.cdc. ties within communities where they live. Links on the
gov/ncbddd/autism/actearly) are available in English and website for families and providers offer comprehensive
Spanish and are designed to help parents recognize any summaries of research findings that relate to improved
delays so that their children can be screened and receive quality of life for families and children.”
early treatment, if necessary. The toolkit includes an infor-
mational card on developmental milestones, a growth chart,
 Working With Families of Young Children With Special Needs 129

TABLE 8-8
STEPS IN THE COLLABORATIVE TRANSITION PROCESS
TIME OF YEAR TASK AND PERSON RESPONSIBLE
November prior Individualized Education Program (IEP) team/preschool team:
to transition into • Writes a kindergarten transition letter to the family of a child receiving special
kindergarten education services who will be eligible for kindergarten the following year
• Asks the family for a response to the transition letter
• Invites the family to become part of a collaborative decision-making team
for the transition
December to Sending school staff, including physical therapist, occupational therapist, and
April speech-language pathologist:
• Observes the receiving kindergarten and meet with kindergarten teachers, related
services staff, and school principal
December to Family (at their convenience with IEP team or separately):
April • Observes the receiving kindergarten and meets with kindergarten teachers, related
services staff, and school principal
December to IEP team and receiving school:
April • Hold an informal collaborative meeting to discuss the transition process

February to April Receiving school:

• Observes the child in the preschool classroom
• Shares information related to child s preparation for entering kindergarten
April to June Physical therapist, occupational therapist, and speech-language pathologist:
• Share relevant progress records
• Makes recommendations to the IEP team regarding goals, activities, and needed
equipment/assistive technology
April to June Parents, parent representatives, sending and receiving school staff, and district
administrator:
• Have the annual IEP review/initial school-age special education meeting to develop
the IEP; all collaborating team members attend and participate
May to June IEP team, including family:
prior year • Participate in the annual IEP meeting
• Discuss the child s progress
• Develop an IEP for the upcoming year
• Discuss changes to anticipate in kindergarten and encourage the family s involvement
April to August Receiving school staff:
• Orders needed materials and equipment
August/ Family and child:
September • Participate in orientation activities
September Receiving school staff:
• Ensures that the child is included in kindergarten with proper supports and
services for success
130 Section 8

SUMMARY
Educational services for young children with special
needs older than 3 are specified in IDEA Part B. The DEC
of the Council for Exceptional Children provides guide-
lines for implementing this law, offering interprofessional Case 8-1: A 3-year-old girl at risk for
best practices for optimizing outcomes for these children. developmental delay
Pediatric therapists play key roles in identifying both fam-
ily and developmental risk factors, selecting age-appropriate Nicole was born at 36 weeks’ gestation via Cesarean
screening and assessment tools commonly used with this section with a 6-day stay in the neonatal intensive care
population, and recognizing the scope of practice for profes- unit (NICU) before going home. Her mother reports that
sionals working with 3- to 5-year-olds. As part of the team Nicole did not smile until 4 months, sat independently at
providing ECSE, therapists must shift their focus from approximately 12 months, and started walking around 29
family-centered EI to child-centered education, supporting to 30 months. She reports that Nicole has received physical
the child’s IEP for academic readiness to enter elementary therapy, occupational therapy, and speech-language therapy
school. Service for these young children and their families since she was 12 months old. She was diagnosed with a
continues to build on advocacy for families’ needs, educa- developmental delay. Nicole is now integrated into a half-
tional services for their children, and community develop- day preschool program 4 mornings a week. She is mobile
ment for increased opportunities for inclusion. in her environment but demonstrates poor balance and uses
a wide base of support, her arms at shoulder height when
walking. Nicole can kick a ball but falls once with 3 kicks.
She ascends and descends stairs in marking time with both
INTERPROFESSIONAL ACTIVITY hands holding onto the rails. She is unable to walk heel to
toe, stand on one foot, or jump. Nicole throws a ball with
Working With Young Children, Their trunk rotation to assist in the throwing motion. She demon-
Families, and Their Teachers strates palmar grip around all objects. Her mother states that
Nicole mainly prefers to use her left hand, but she does not
As you look at the following case studies, review the rel- currently show any hand preference when coloring and will
evant information, reflect on the roles of all involved, and switch hand usage. Nicole uses her thumb and all 4 fingers
answer each of the following questions with your interpro- to grasp smaller-sized objects and turn the pages of a thick
fes-sional team: book. She has limited social play skills and prefers to play by
1. How would you describe your role in the ECSE pro- herself. Her attention span is limited, and she is distracted
gram to this family? if the task is too hard for her to complete. She is unable to
2. Based upon criteria given in the case, is the child eli- understand or follow simple tasks, requiring extra cues from
gible for ECSE? adults. She has difficulty expressing her wants and needs to
3. What concerns do you think a preschool teacher peers and adults. Her developmental screening continues to
would have about the child? reveal functional skills at the developmental age of 15 to 20
months.
4. How would you communicate with the family, given
their situation?
Case 8-2: A 4-year-old boy with
5. As a team, how would you organize your assessment
of the child? cerebral palsy
6. What types of recommendations would you make in Adam is a 4-year-old boy with spastic cerebral palsy
terms of functional goals, based upon IDEA Part B? presenting with intermittent hypertonicity of all extremities
7. What information would you give the parents and and hypotonicity of head, neck, and trunk. He has obligato-
teacher to promote advocacy? ry tonic reflexes for asymmetrical tonic neck reflex (ANTR)
8. How would you help this child and his/her family and symmetrical tonic neck reflex (STNR) and poor gross
transition to elementary school? motor control. Adam has fair fine motor control of his left
hand/fingers when provided postural support in a position
chair with lap tray. When positioned properly, he is able to
reach and grasp items asymmetrically with his left hand/
arm. He has limited right arm and hand use and requires
physical cues to place in midline for hold-and-do tasks.
 Working With Families of Young Children With Special Needs 131

When concentrating on throwing or maneuvering with his arms get caught in the wheelchair during the bus ride to
left hand/arm, his right hand is observed to present with pal- and from school. When Art is properly positioned, he is able
mar reflex as he clutches fingers together tightly. Although to activate a switch for cause and effect toys using elbow
cognition appears to be on target, his speech is severely dys- motion to press down on the “big red button.” The IEP pre-
arthric, making communication a concern. It is often hard school team is addressing positioning and communication
to hear Adam as he speaks due to limited breath control. He needs during the day. Another area of importance is to create
is unable to assume sitting or standing and cannot maintain an area in the preschool room that can be modified to help
sitting without support and physical assistance. He is depen- reduce Art’s tendency to become overstimulated by sensory
dent upon an adult for mobility in a manual wheelchair that input, allowing him to engage in functional and play tasks.
he is currently outgrowing. Adam currently has a normal The development of Art’s oral motor skills is of importance
body mass index for his age. He likes to look at books and is to his family as they are fearful of recommended placement
developing reading skills. He watches and will interact with of a gastrostomy tube (G-tube) for his feeding and nutri-
peers if they are within his proximity. Adam will be going to tional needs. Frequent discussion and contact between the
a new elementary school next fall, and the IEP team will be school, family, and other professionals working with Art is
addressing his needs for adaptive equipment and devices to essential.
function in the kindergarten classroom. His mother would
like recommendations for therapeutic positioning to prevent Case 8-4: A 3-year-old boy with
deformities, continued focus on Adam becoming toilet autism spectrum disorder
trained, and options for assistive technology to keep up with
the kindergarten curriculum. Caleb is a 3 year 6 month old boy with a diagnosis of
ASD and developmental delay. He lives at home with his
Case 8-3: A 3-year-old boy with parents and older brother who is home-schooled. His mother
cerebral palsy reports that she had a normal pregnancy and that Caleb
was delivered by C-section. His developmental milestones
Art is a 3 year 11 month old boy who was born pre- are delayed in the areas of communication and motor skills.
maturely (at 32 weeks’ gestation) via emergency Cesarean There is a family history of ASD, seizures, and diabetes and
section (C-section) due to fetal distress. He weighed 2250 heart problems.
grams at birth (low birth weight) and remained in NICU Caleb has received educational services through First
for 6 weeks with ventilation. Art’s feeding was poor; he had Steps (EI) and is currently attending ECSE and receiving
a weak suck; and he had difficulty coordinating respiration. physical therapy, occupational therapy, and speech-language
Motor milestones were delayed due to persistent primitive pathology services. He requires one-on-one direction for
reflexes, variable muscle tone and intermittent clonus. Art preacademic and the majority of functional tasks. He consis-
was diagnosed with cerebral palsy, athetoid type prior to his tently displays self-stimulatory behaviors when not engaged.
first birthday. Art has been followed by physical therapy, Typical sensory behaviors for Caleb include arm/hand flap-
occupational therapy, and speech-language pathology since ping, twirling a toy/object, flicking fingers at lights in room,
birth and through a children’s therapy center prior to tran- and twirling his body in circles. He will run, but will put
sitioning to a LEA preschool program. Art currently attends his arms out in a medium guard position. His balance and
preschool 5 mornings a week for special education and coordination are delayed for climbing stairs, throwing and
related services in addition to receiving weekly therapeutic catching balls, and jumping or standing on one foot. Caleb
services in the home. enjoys swinging, but becomes agitated if assisted to climb
Art displays irregular, involuntary movements of arms upon other playground equipment (eg, monkey bars, slide).
and legs. He can become quite excited when the other He often gets upset when he has to be brought in from recess
children are around him which increases his muscle tone activities. He is able to imitate simple motor actions with
and movements. His jerky movements make it extremely practice. He avoids using classroom tools such as scissors,
difficult to isolate movement of one part of his body. chalk, markers, and brushes. His attention to non-preferred
Accessibility for Art is a key focus of his IEP preschool team tasks is limited. He is visually distracted by events occur-
for social participation and functional control/coordination ring in the classroom and can become over stimulated from
to assist with his play, gross motor, fine motor, and self-care noise and will cover his ears. He will spend time looking at
tasks. He is dependent upon adults for postural control, a computer screen and iPad if allowed. During snack time,
functional mobility, hygiene (toilet care), and feeding. Prior Caleb eats only preferred items such as chips and crackers.
to transitioning to preschool programming, Art received a He uses his fingers to eat and will not try fruit or vegetable
customized wheelchair with tray and is currently being fit- items. He is able to drink from a straw but needs help to
ted for new ankle foot orthoses to provide postural support. open milk carton. Caleb has limited speech and will repeat
When he is on a crowded bus, Art becomes excited and his sing-song rhymes, or repeat simple greetings such as “Hi,
132 Section 8

hi,” or “Goodbye, goodbye.” He often walks out of his shoes, tongue to the side to initiate a munching/chewing pattern.
and is unaware of his coat or backpack and what he should She grinds her teeth during nonfood activities. She is depen-
do with these items. dent in hygiene and dressing activities. She will quiet her
arms while being dressed with a shirt or coat. She smiles and
Case 8-5: A 4-year-old girl with enjoys music and animated videos with her peers.
multiple disabilities
Monica is 4 years 7 months old with a diagnosis of 18q
syndrome, ocular apraxia. This syndrome causes growth
REFERENCES
problems and developmental delays. She lives with her 1. Center for Parent Resources and Information. Part B of IDEA:
parents and younger brother and sister. Monica’s family Services for School-Aged Children. Center for Parent Resources and
is involved with many medical needs and regularly com- Information Web site. http://www.parentcenterhub.org/repository/
partb/. Published September 24, 2010. Accessed January 24, 2017.
municates with preschool staff. She has received services
2. Division of Early Childhood. DEC recommended practices in early
since infancy and is being evaluated as she transitions into intervention/early childhood special education. Division of Early
school-age programming next fall. She is currently in an Childhood Web site. http://www.dec-sped.org/dec-recommended-
ECSE classroom and receives physical therapy, occupational practices. Published 2014. Accessed January 24, 2017.
therapy, speech-language therapy, and special education pro- 3. Verenikina I. Scaffolding and learning: Its role in nurturing new
learners. In: Kell P, Vialle W, Konza D, Vogl G, eds. Learning and the
gramming. She is nonambulatory and has a wheelchair with
Learner: Exploring Learning for New Times. Wollongong, Australia:
customized tray. Monica is able to sit without support for University of Wollongong; 2008:236.
longer periods of time (4 to 6 minutes) and demonstrates fair 4. Morin A. ADHD: What you’re seeing in your preschooler. Understood
postural control while in sitting position with proper setup. Web site. https://www.understood.org/en/learning-attention-issues/
She does not have protective responses to catch herself if she child-learning-disabilities/add-adhd/adhd-what-youre-seeing-in-
your-preschooler?gclid=Cj0KEQiAwrbEBRDqxqzMsrTGmogBEiQ
loses her balance in sitting. When pulled to sit, she is able
AeSE6ZQnNqaCl5cI2kglJs6JzrZ79Xjqb6sfAIOBph0hEOEQaAtX-
to maintain her head in midline position. She presents with e8P8HAQ. Published 2014. Accessed January 27, 2017.
decreased muscle tone overall. She does have full range of 5. US Department of Education. Building the Legacy: IDEA 2004. US
motion for arms, hands, and legs. With positioning and lap Department of Education Web site. http://idea.ed.gov/explore/view/
tray, Monica is able to reach and grasp medium-sized objects p/,root,regs,300,D,300.304,.html. Published July, 2013. Accessed
December 11, 2017.
with elbow extended, forearm pronated, and wrist flexed.
6. Rainforth B. Analysis of physical therapy practice acts: implica-
She attempts to grab smaller objects using a raking motion tions for role release in educational environments. Pediatric Physical
with her fingers. She is able to poke or press a switch with Therapy. 1997;9:54-61.
either her right or left palm or index finger when positioned 7. Bose P, Hinojosa J. Reported experiences from occupational therapist
in a prone stander with tray. interacting with teachers in inclusive early childhood classroom. Am J
Occup Ther. 2008;62:289-297.
Monica is dependent upon adults for feeding. She typi- 8. DEC. Promoting the Health, Safety and Well-Being of Young
cally holds her mouth in an open position, with drooling Children with Disabilities and Developmental Delays. University
observed. When food is introduced, she holds her head of Kansas Web site. https://kskits.drupal.ku.edu/sites/kskits.drupal.
in extensor pattern. She is able to close her lips around a ku.edu/files/docs/DEC_Promoting_the_Health_Safety_Well_Being.
straw and suck for regular liquids, with some spillage as pdf. Published September, 2012. Accessed December 11, 2017.
9. Turnbull A, Turnbull R, Erwin E, Soodak L, Shogren KA. Families,
she releases the straw from her lips. Monica has minimal Professionals and Exceptionality: Positive Outcomes Through Partnership
spillage when taking thickened or semisolid liquids from a and Trust. 6th ed. Upper Saddle River, NJ: Pearson; 2011.
nosey cup. She will not bite solid-type foods. Monica uses 10. Fenlon A. Paving the way to kindergarten for young children with
a munching/chewing pattern of her jaw and lips when food disabilities. Reading Rockets Web site. http://www.readingrock-
items are placed on her tongue. She has limited lateral, side- ets.org/article/paving-way-kindergarten-young-children-disabilities.
Published 2005. Accessed January 24, 2017.
to-side movements of her tongue. When provided food items
to the side of her mouth, Monica is beginning to move her
Section 9
Providing Support for Children
5 to 21 Years in the Educational Setting
Joan Delahunt, OTD, MS, OTR/L; Mildred Oligbo, PT, DPT; Pamela Hart, PhD, CCC-SLP;
and Catherine Rush Thompson, PT, PhD, MS

chronic conditions. Finally, it offers suggestions of how to

OVERVIEW build a children’s self-advocacy as they develop into adults.
Upon completion of this section, the learner will be able
This section builds on foundational interprofessional to (1) describe common risk factors that are encountered
concepts, discussing how physical therapists, occupational in educational settings, (2) compare and contrast tests and
therapists, and speech-language pathologists work collab- measures used by team members, (3) describe evidence-
oratively with others to support school-aged students in based interprofessional strategies used in school settings,
educational settings. While many children with congenital and (4) discuss how the interprofessional team can empower
problems receive therapy services from birth through early children and adolescents to advocate for themselves.
intervention (EI) services and early childhood special educa-
tion (ECSE), others begin receiving special education at age
5 or later. This section illustrates how the interprofessional
team supports a child’s education from 5 to 22 years of age, INTERPROFESSIONAL SCHOOL SERVICES
describing common risk factors, including bullying and
cyberbullying, obesity, youth suicide, concussions, addiction Occupational therapists, physical therapists, and speech-
to drugs, internet addiction, school violence, low socioeco- language pathologists play important roles in the education-
nomic level, and academic failure. It also provides a range of al programming for children with special needs. In school
discipline-specific and interprofessional tests and measures settings, therapists and educators work together to support
commonly used in educational settings. In addition, it offers children with special needs across academic, psychosocial,
suggestions for evidence-based strategies that can be used and sensorimotor areas of development. The overarching
for team management of pediatric conditions commonly goal of these collaborative services is to support each child’s
seen in elementary, middle, and high schools, including ability to achieve her highest potential within the educa-
long-term therapeutic support provided to children with tional curriculum. As such, therapists and educators must

Thompson CR. Pediatric Therapy:

An Interprofessional Framework for Practice (pp 133-148).
- 133 - © 2018 SLACK Incorporated.
134 Section 9

have extensive knowledge of individualized assessment and

intervention, the range of possible assistive technologies to
SCREENING AND EVALUATION
provide children the opportunity to access learning materi-
als, and an understanding of how classroom design may Assessment of an individual student involves a multitude
impact learning for specific children. All children, regard- of factors, including age of the student, type of educational
less of the severity of their disability, are entitled to a free setting, specific areas of concern for the student, availability
appropriate public education (FAPE) in the least restrictive of screening and evaluation tools, and which professional
environment (LRE). It is the role of interprofessional special team members should contribute to this process. As a school
education teams to address learning challenges and barriers team, each member is asked to (1) provide individual view-
so that each child is able to reach her highest learning poten- points on what areas should be assessed, (2) suggest par-
tial, as discussed in Section 8. ticular tools for assessment, (3) complete the agreed-upon
assessment(s), (4) document assessment results, and (5) pro-
vide recommendations based upon interprofessional clinical
decision making. Interprofessional collaboration emphasizes
CONSIDERATION OF RISK AND the expectation of all team members working in concert to
PROTECTIVE FACTORS IN AN provide a comprehensive picture of each student’s strengths
and areas of concern.
EDUCATIONAL SETTING Within educational settings, specific guidelines for the
process of qualifying a student for special education services
Within educational settings, children, adolescents and helps to guide the interdisciplinary team in determining the
young adults may encounter risk factors that can affect focus for the initial evaluation. As a team, each member
learning and participation. In this context, a risk factor is shares her observations of the student, and collaboratively
defined as an individual or environmental characteristic, they develop an evaluation plan that can be set into motion.
condition, or behavior that increases the chance that a nega- During this process, each practitioner must openly discuss
tive outcome will occur.1 Conversely, the presence of protec- her concerns and ideas for evaluating specific areas of need.
tive factors, including social support and unique individual Physical therapists, occupational therapists, and speech-
or environmental characteristics, conditions, or behaviors, language pathologists have unique expertise and discipline-
can reduce the negative impact of risk factors.1 The presence specific tests and measures that address categories outlined in
or absence, as well as the various combinations of protective the International Classification of Functioning, Disabilities,
and risk factors, contributes to the overall health of children and Health (ICF) Model (Table 9-1).11 Although discipline-
and youth. specific tests are useful in isolated situations, most assess-
Common risk factors facing students include bullying ments designed for use within educational settings are inter-
and cyberbullying,2 obesity,3 youth suicide,4 concussions,5 disciplinary in nature. Thus, team members are encouraged
addiction to drugs,6 internet addiction,7 school violence,8 to perform screening and/or evaluation assessments collabor-
low socioeconomic level,9 and academic failure.10 Students’ atively within the same educational environment(s), such as
protective factors include, but are not limited to, emotional the classroom, gymnasium, playground, cafeteria, hallway,
self-regulation, active engagement with school, positive bathroom, or school bus. This shared experience allows for
engagement with peers, and athletics.1 Professionals work- rich dialogue among all professionals. Additionally, this col-
ing in educational settings can serve as protective factors laboration ensures a comprehensive plan of care culminating
through mentoring and providing clear expectations for in the Individualized Education Plan (IEP),12 as detailed in
behavior and physical/psychological safety.1 All of these Section 8. However, some situations exist where team-based
protective factors aid in counterbalancing the negative risk assessments do not provide enough detailed information
factors’ effect on youth.1 Children and youth with medical about a student’s performance. Individual school profession-
conditions and disabilities are at increased risk for many als may decide to assess the student independently, using
of these risk factors, particularly obesity and bullying.4 discipline-specific measures to provide detailed data. The
Conditions associated with an increased risk of suicide decision to complete an interdisciplinary team evaluation or
include chronic pain, loss of mobility, disfigurement, cogni- several discipline-specific evaluations depends upon key fac-
tive styles that make problem solving a challenge, asthma, tors, including (1) the familiarity of the team members with
multiple sclerosis, and spinal cord injuries.4 All school one another, (2) the intended purpose of the evaluation data,
personnel, including pediatric therapists, can provide social (3) the severity and chronicity of the student’s condition, (4)
support and help children develop the protective factors that prior evaluation data from other sources, (5) the availability
can help prevent academic failure. of assessment tools, (6) time available for evaluation, and (7)
state regulations regarding accepted assessment tools.
 Providing Support for Children 5 to 21 Years in the Educational Setting 135

TABLE 9-1
DISCIPLINE-SPECIFIC ROLES AND RESPONSIBILITIES IN SCHOOL SETTINGS
RELATED PRIMARY FUNCTION IN SCHOOL SETTINGS
SERVICES
Physical therapy • Mobility throughout the school: Training the child to move as independently as possible
through hallways, negotiate stairs, and move on the playground (this may involve the
use of adaptive and assistive devices, such as customized motorized wheelchairs,
walkers, crutches, and orthotics)
• Transfers at school: Teaching the child how to perform safe and efficient transfers
to/from therapeutic equipment, transportation, desk seat, and toilet
• Postural control: Positioning the child to facilitate attention, comfort, and safety during
learning activities while preventing secondary complications
• Motor skills: Enabling the child to engage in school-related activities (eg, gym, adaptive
physical education, field trips, playground activities)
• Cardiopulmonary rehabilitation: Ensuring that children with decreased endurance have
properly paced activities throughout the school day
• Neuromuscular training: Providing resources to enhance motor control
• Education of stakeholders: School team members, children with special needs, all
children in the school setting, families, legislators, community members
Speech- • Articulation
language • Language
therapy • Social communication
• Play
• Voice
• Resonance
• Fluency
• Social Skills
• Feeding and Swallowing
• Cognition
• Literacy
• Augmentative communication
• Oral motor and swallowing
• Learning and cognition
• Education to team and family
Occupational • Play and learning
therapy • Functional motor skills (self-help, eating, managing personal items, toileting)
• Preacademics (hand skills, prewriting, visual perceptual skills)
• Social participation
• Sensorimotor skills
• Behavior regulation skills
• Feeding and oral motor skills
• Adaptive equipment/positioning
• Assistive devices
• Education to team and family
136 Section 9

Common areas of concern for students with special needs

range from their issues related to mental health and physical
RESPONSE TO INTERVENTION
performance to environmental factors impacting a child’s
ability to learn. Practitioners can work collaboratively to One collaborative process used to deliver services in
determine which assessments best detect risk factors and educational settings is called Response to Intervention (RtI).
issues impacting each child’s learning. Table 9-2 displays the RtI is a multitiered approach designed for the early identi-
broad areas of concern paired with, based upon categories fication and support of students with learning and behavior
in the ICF Model, examples of team-based assessments and needs.13,14 Within this methodical process, school pro-
suggested team members. Additional details about these fessionals gather to follow the recommended guidelines
tests and measures are listed in Appendix B. implicit within each tier and outlined in this model. School
professionals may be asked to assist general education teach-
ers within this practice. The RtI process begins with high-
quality instruction and universal screening of all children in
SCHOOL-BASED INTERVENTIONS the general education classroom.13,14
Common issues within the general education classroom
The educational environment provides a setting where include difficulties with handwriting, language, social
students with special needs are given supports to aid their interaction, sitting at a desk, following directions, and read-
learning and development into adulthood. Within this ing and math skills. General education teachers identify a
complex environment, multiple factors influence the suc- student’s specific challenges and initiate the 3-tiered RtI
cess of each child’s ability to benefit from his educational process. Tier 1 involves whole-class intervention strategies;
experience. After identifying risk factors impacting a child’s Tier 2 focuses on small-group interventions; while Tier 3
education, school professionals work together to foster the is reserved for individualized, intensive interventions.13 RtI
student’s protective factors while developing additional strat- addresses both the academic and behavioral health needs of
egies to boost the child’s resilience. all students, particularly those at risk. Figure 9-1 illustrates
Throughout the country, school professionals typically the tiered RtI model used to provide appropriate, inclusive
gather together weekly to discuss students who display at- services for children identified at-risk in the classroom.
risk behaviors in the school setting. In this dialogue, each Pediatric professionals can contribute to this tiered pro-
professional shares observations and suggestions to assist cess through consultation and classroom support. Speech-
the student. Teams also review each student’s protective language pathologists, occupational therapists, and physical
factors, which may include a supportive family, close com- therapists are most commonly involved in Tier 3 interven-
munication with a trusted teacher, and/or the student’s tions but may be invited to assist at any tier. For example,
level of motivation to achieve high grades. Together the within Tier 1, the teacher may invite the occupational
team assesses all factors and provides a support plan for therapist to suggest age-appropriate self-care and fine motor
the particular student. This plan might incorporate the skills that enable children of all ability levels to succeed.
speech-language pathologist as a motivator for the student Tier 2 interventions involve small groups, so the physical
to participate in recess by developing a plan for using a peer therapist may assist in adaptive physical education classes,
buddy to facilitate playing on the playground equipment. aiding children needing additional physical prompts or
Another example might be the school nurse, physical thera- supports. Tier 3 interventions are more intensive and spe-
pist, and occupational therapist working together to initiate cialized to individual students. At this tier, pediatric profes-
a “healthy choices after school program” to target students sionals work directly with the student on targeted skills to
with obesity. Physical therapists and occupational therapists determine whether an IEP is needed. An example of Tier 3
may team with high school football coaches on concussion interventions includes a speech-language pathologist work-
prevention and management programs. Through creative ing for a trial of 4 sessions with a first-grade student on
planning, school teams can work to address risk factors producing developmentally appropriate sounds correctly
affecting students to facilitate improved educational out- in his speech. Following this structured intervention, the
comes. Table 9-3 lists common problems or risk factors therapist may encourage a transdisciplinary approach for
encountered in the school setting, protective factors, and reinforcing this skill development. The speech-language
interprofessional strategies commonly used to manage these pathologist would provide discipline-specific assessments
problems. and high-quality, evidence-based instructional methods
and interventions; data collection and data-based decision
making; and progress monitoring. Across all 3 tiers of RtI,
pediatric professionals seek to find strategies to effectively
integrate evidence-based interventions into the daily school
routines of the student.15,16
 Providing Support for Children 5 to 21 Years in the Educational Setting 137

TABLE 9-2
INTERPROFESSIONAL ASSESSMENTS IN THE EDUCATIONAL SETTING
CATEGORY ASSESSMENT DESCRIPTION INTERPROFESSIONAL TEAM
MEMBERS
Participation Scales of Measures functional independence School psychologist, physical
(including Independent and adaptive functioning (motor therapist, occupational
activities, Behavior-Revised skills, social interaction and therapist, speech-language
environmental (SIB-R) communication skills, personal living pathologist, general education
factors) Ages: 3 months to skills, and community living skills) teachers, special education
over 90 years in school, home, employment, and teacher, behavior
community settings therapist, parents
School Function Measures function in the school Physical therapist, occupational
Assessment (SFA) environment, including participation in therapist, school counselor,
Ages: Elementary school activity settings, task general education
school students supports, and activity teachers, special
performance (physical and
cognitive/behavioral tasks)
Activities Assessment of Provides a systematic way to Behavior therapist, occupational
(including Functional Living evaluate, track, and teach functional, therapist, general education
function in Skills (AFLS) adaptive, and self-help skills teacher, special education
educational Ages: 2 years teacher, school psychologist,
settings) and up speech-language pathologist
Assessment of An observational assessment with Physical therapist, occupational
Motor and Process 16 motor and 20 process skills items, therapist, speech-language
Skills (AMPS) including complex or instrumental pathologist, general
and personal activities of daily living education teacher, special
education teacher
Bruininks- Assesses balance, strength, Physical therapist,
Oseretsky Test of coordination, running speed and occupational therapist
Motor Proficiency agility, upper limb coordination (ball
(BOTMP) Ages: skills), dexterity, fine motor control,
4½ to 14½ years visual-motor
Developmental Criterion-referenced assessment with Physical therapist, occupational
Assessment for 5 scales to measure rate of therapist, general education
Individuals with developmental progress teacher, special education
Severe Disabilities‒ teacher, school psychologist,
Third Edition speech-language pathologist
(DASH-3)
Functional Determines a person s ability to Behavior therapist, occupational
Independence perform certain functional activities therapist, general education
Skills Handbook from daily life. It was developed for teacher, special education
(FISH) special education teachers, teacher, school psychologist,
paraeducators, and parents working speech-language pathologist
with individuals with severe
developmental disabilities.
(continued)
138 Section 9

TABLE 9-2 (CONTINUED)

INTERPROFESSIONAL ASSESSMENTS IN THE EDUCATIONAL SETTING
CATEGORY ASSESSMENT DESCRIPTION INTERPROFESSIONAL TEAM
MEMBERS
Activities Functional Assesses and teaches students Occupational therapist, general
(including Assessment and with moderate to severe education teacher, special education
function in Curriculum for developmental disabilities teacher, school psychologist,
educational Teaching Everyday everyday routines speech-language pathologist
settings) Routines (FACTER)
Pediatric Evaluation Uses 271 items to assess Parent, general education teacher,
of Disability self-care (eating, grooming, special education teacher, physical
Inventory (PEDI) dressing, bathing, toileting), therapist, occupational therapist,
Ages: 6 months to mobility (transfers, indoors and speech-language pathologist
7 years, 6 months outdoors mobility), and social
function (communication,
social interaction, household
and community tasks); includes
scales for environmental
modification and amount of
caregiver assistance
Vineland Adaptive Measures adaptive behavior School psychologist, physical
Behavior Scales (motor, social interaction and therapist, occupational therapist,
(VABS) communication, self-care skills speech-language pathologist,
Ages: Birth to and community skills) general education teachers, special
90 years education teacher, behavior
therapist, parents
Impairments Behavioral Uses a 30-item rating scale for School psychologist, counselor,
(focus on and Emotional child-reported risks for occupational therapist, school nurse,
mental Screening System behavioral and general education teacher, special
health)38,43 Student Self- emotional problems education teacher, behavior
Report Form (BESS) specialist, principal
Grades: 3 to 12
Patient Health Screen for anxiety School psychologist, school
Questionnaire-9 counselor, general education
item teacher, special education teacher,
Grades: 6 to 12 occupational therapist, school nurse,
principal, physical therapist
5-Item Screen for Screen for anxiety School psychologist, school
Child Anxiety- counselor, general education
Related Emotional teacher, special education teacher,
Disorders occupational therapist, school nurse,
Grades: 6 to 12 principal, physical therapist
 TABLE 9-3
RISK FACTORS AND INTERPROFESSIONAL MANAGEMENT
RISK FACTOR PROTECTIVE FACTOR STRATEGY DESCRIPTION TEAM MEMBERS
Bullying40 and cyberbullying47 • Social support • Create a community • All team members
• Opportunities for children to for adults and pupils to and school
talk about problems send a unified message
• Be as obvious about against cyberbullying/
discussing cyberbullying as bullying
bullying face-to-face48 • Install a cell phone
monitoring app (eg, Pumpic)
Obesity44,46 • Support group, including • Healthy choices • Teacher, occupational
team members and after-school program39 therapist, physical
at-risk youth • Graded exercise therapist, school
programs nurse, school
nutritionist
Youth suicide42 • A crisis intervention team • Identify at-risk student • All team members
The most frequently cited risk factors for suicide are: • Receiving effective mental through a risk assessment and school staff
• Major depression (feeling down in a way that health care
impacts your daily life) or bipolar disorder • Positive connections to
(severe mood swings) family, peers, community,
• Problems with alcohol or drugs and social institutions such
as marriage and religion that
• Unusual thoughts and behavior or confusion
foster resilience
about reality
• The skills and ability to
• Personality traits that create a pattern of intense,
solve problems
unstable relationships or trouble with the law
• Impulsivity and aggression, especially along
with a mental disorder
• Previous suicide attempt or family history of a
suicide attempt or mental disorder
• Serious medical condition and/or pain
Concussion49,50 • Close coach-player • Concussion • Teacher, physical
relationship prevention program therapist,
• Neck strength is a significant • Protective helmets occupational
Providing Support for Children 5 to 21 Years in the Educational Setting

predictor for concussion49 and facial protective therapist, speech-

equipment50 language pathologist,
football coach, school
139

psychologist
(continued)
 140
Section 9

TABLE 9-3 (CONTINUED)

RISK FACTORS AND INTERPROFESSIONAL MANAGEMENT
RISK FACTOR PROTECTIVE FACTOR STRATEGY DESCRIPTION TEAM MEMBERS
Drug addiction • School domain protective factors51 • Involve students with clubs at school • Teacher, coach,
and substance • Opportunities for youths who • Provide teacher-student mentors occupational therapist,
abuse45 perceive more chances • Educate students about drugs and drug abuse school counselor,
• Involvement in prosocial activities social worker
• Offer support groups to students and their parents
• Involvement in school who struggle with drug or substance abuse
• Rewards for prosocial youths
Internet • Parent-child relationship52 • Surround students with a supportive environment • Teacher, social worker,
addiction52 • Emotional regulation52 • Controlling the computer and internet use school counselor,
• Promoting book reading occupational
therapist, speech-
• Providing treatment to those with a
language pathologist
psychological problem
School • Intensive supervision52 • Strong connections with students and • Teachers, school
violence53 • Clear behavior rules52 school professionals52 counselor, speech-
• Consistent negative reinforcement • Commitment to school (an investment in school language pathologist,
of aggression52 and in doing well at school)52 occupational therapist,
• Close relationships with peer role models52 physical therapist, social
• Engagement of parents
worker, coach,
and teachers52 • Membership in peer groups that do not promote
building principal
antisocial behavior52
• Involvement in prosocial activities52

(continued)
 TABLE 9-3 (CONTINUED)
RISK FACTORS AND INTERPROFESSIONAL MANAGEMENT
RISK FACTOR PROTECTIVE FACTOR STRATEGY DESCRIPTION TEAM MEMBERS
Academic • Strong relationship between • Perceived adult support • Teachers, school
failure53 school connectedness and • Relationships with strong peers counselor, speech-
educational outcomes53 • Dedication to school by both students language pathologist,
• School attendance53 and school personnel occupational
• Staying in school longer53 therapist, physical
therapist, coach,
• Higher grades and classroom
building principal
test scores53
• Students who do well
academically are less likely to
engage in risky behaviors53
Low socioeco- • Adult caring and support56 • Engage community partners to provide a range of • Teachers, school
nomic status54 • Opportunities for meaningful services at the school that students and their families counselor, speech-
participation56 need, such as dental services, health screenings, child language pathologist,
• High expectations56 care, substance abuse treatment)54,55 occupational
• Nurturing staff and positive role models56 therapist, physical
• Creative, supportive school leadership56 therapist, coach,
building principal
• Peer support, cooperation, and mentoring56
• Personal attention and interest from teachers56
• Warm, responsive school climate56
• Minimum mastery of basic skills56
• Emphasis on higher-order academics56
• Avoidance of negative labeling and tracking56
• Leadership and decision-making by students56
• Student participation in extracurricular activities56
• Parent and community participation in instruction56
• Culturally diverse curricula and experiences56
Providing Support for Children 5 to 21 Years in the Educational Setting
141
142 Section 9

Figure 9-1. Response to intervention strategies used in school settings.

A key variable present with children with chronic con-

INTERPROFESSIONAL MANAGEMENT dition is stress.21 Stress for children with chronic condi-
FOR COMMON CHRONIC CONDITIONS tions can be described as a state of mental or emotional
strain or tension resulting from adverse or very demanding
Students with chronic conditions commonly qualify for circumstances.21 Stresses in childhood differ from those
special education services. Chronic conditions are defined experienced by adults. Table 9-4 provides a list of common
as health issues that have persisted for 3 months or more, stressors experienced by children and youth.
impacting a child’s normal daily activities and typically Recognizing potential stressors and students’ emotional
involving extensive medical care.17 Evidence reveals that the responses and identifying and reducing the stress triggers
current prevalence of pediatric chronic conditions averages can effectively build trust among the student, the fam-
26%.18 Some examples of chronic conditions include, but ily, and the school team. Guided by the special education
are not limited to, asthma, diabetes, cerebral palsy, sickle cell process, school professionals can incorporate data gathered
anemia, cystic fibrosis, cancer, aids, epilepsy, spina bifida, from a variety of sources (eg, student observations within
obesity, and congenital heart defects.19-22 school settings, attendance records, results of previous and
Chronic health conditions during childhood and ado- current assessments, interviews) to generate a comprehen-
lescence impact physical, emotional, and/or mental func- sive individualized plan that incorporates stress reduction.
tioning, leading to disruptions in school attendance and Details of this plan might include strategies for completing
in completion of school work.18 Due to their high number assigned work when the student is receiving extended medi-
of required hospitalizations and ongoing medical appoint- cal treatment, scheduling in planned rest breaks at school,
ments, students with chronic conditions do not enjoy the or creating a protocol to guide consistent care following a
consistency of school participation compared with their seizure at school.
peers. Therefore, school professionals must collaborate to Designing specific plans to support individual students
create cohesive plans to support these particular students living with chronic conditions requires clear communication
to maintain active engagement within the educational set- among all school professionals, from the administrator to the
ting.15,16 For children with complex medical conditions, paraprofessional aide. Additionally, time to meet and review
physical therapists, occupational therapists, and speech- current support plans is imperative. Many schools incorpo-
language pathologists serve as ongoing school-based health rate weekly school assistance team meetings into their calen-
care resources for students, teachers, and parents. dar to ensure consistency with expectations and outcomes.
 TABLE 9-4
STRESSORS AND STRESS MANAGEMENT FOR CHILDREN AND YOUTH
AGES STRESSOR SIGNS OF STRESS SOLUTION
Across • Inability to meet demands • Changes in behavior: Refer to the school counselor or
lifespan • Over-challenging situations (where the students º Acting irritable psychologist if behaviors persist:
resources do not meet the demands) or moody • Listen and observe closely
• Changes in schedules, changes in plans º Withdrawing from • Mitigate losses
• Daily hassles activities that used to • Help students develop strategies to
• Major life events: pregnancy, moving give them pleasure reduce the impact of losses
• Minor losses (time, money, distant friends) º Routinely expressing • Build self-confidence and
worries coping skills
• Major losses (money, friends, pets, parent[s] death or
divorce, job, personal relationship) º Complaining more than • Maintain a routine
usual about school • Give opportunities for choice and
• Personal disability
º Crying, displaying taking control
6 yrs • Meeting parent expectations surprising fearful
• Full-time school schedule • Respect the students
reactions personal rights
7 yrs • Need for praise from family and peers º Clinging to others • Treat students fairly
• Being forced to leave a favorite activity º Sleeping too much or • Maintain a structured social
too little schedule, allowing students to
8 yrs • Physical appearance
• Abilities compared with peers º Eating too much or opt out
too little • Encourage physical activity
• Need for positive feedback
• Lack of choice • Model healthy behaviors
9 yrs • Fear of embarrassment
10 to 12 yrs • Puberty: developing at different rates
• Over-extended schedules
• Lack of freedom
• Peer pressure
13 to 18 yrs • School pressures/deadlines • Significantly avoiding
• Involvement in too many activities teachers
• Physical appearance • Long-term absences
• Peer acceptance • Not completing schoolwork
Adapted from American Psychological Association. Identifying signs of stress in your children and teens. American Psychological Association Web site. http://www.apa.org/helpcen-
Providing Support for Children 5 to 21 Years in the Educational Setting

ter/stress-children.aspx. Accessed February 17, 2017; American Academy of Pediatrics. Helping children handle stress. HealthyChildren Web site. https://www.healthychildren.org/
English/healthy-living/emotional-wellness/Pages/Helping-Children-Handle-Stress.aspx. Updated November 21, 2015. Accessed February 16, 2017; and National Association of School
Psychologists. Stress in children and adolescents: Tips for parents. St. Mary s County Public Schools Web site. https://schools.smcps.org/fairlead/images/pdfs/Stress.pdf. Published 2008.
Accessed February 17, 2017.
143
144 Section 9

During these meetings, team members share their expertise In contrast, mothers of children in specialized settings
with one another with the goal of creating a unified plan to reported an understanding of the potential benefits of
meet each student’s individual needs. For example, a physi- an inclusive placement for their children but were more
cal therapist might meet with the special education teacher, comfortable with the services their children received in the
occupational therapist, and paraprofessional aide to review specialized setting. Mothers of children in both types of set-
mobility activities and therapeutic positioning for a child tings reported fears that their children would be made fun
with spastic cerebral palsy. The occupational therapist might of in regular classroom environments.25
provide adaptations for taking notes during class, such as The long-term impacts of initial educational placement
using a recorder (including the student’s ability to operate it decisions are substantial. Researchers have reported the criti-
independently). Similarly, the speech-language pathologist cal need to maximize learning opportunities for children
may discuss a student’s communication skills, elaborating with severe disabilities during the school years because fewer
on vocabulary that meets the unique social and emotional changes in social, educational, and cognitive skills occur
needs of the child. This educational training ensures that after children leave school settings. These initial decisions
all members of the team receive the same information and regarding educational placement tend to remain constant
understand scheduled activities, the frequency and duration across a child’s school career and eventually influence
of interventions, and who is responsible for their imple- postsecondary placement decisions in the community.26-28
mentation. Documentation of team interaction is crucial One study found that graduated students with special needs
to ensure consistency. Examples may include team meeting who had been educated in regular classroom environments
notes, a copy of the child’s revised schedule, handouts for obtained jobs and other independent life skills to a much
specific exercises, and/or positioning recommendations for higher degree than those educated in special classroom
eating in the cafeteria, on the school bus, or sitting at a desk. placements.29 Likewise, in a 5-state study of 40 students
with special needs, those educated in inclusive settings dem-
onstrated significantly higher skills in adaptive and social
LEGAL AND ETHICAL ISSUES IN behaviors than children who received services in segregated
environments.30
SCHOOL SETTINGS Specific to children with highly complex needs requir-
ing multiple services, the best outcomes have been reported
As described in Section 8, the Individuals with Disabilities for individuals educated in regular classrooms.31 Similarly,
Education Act (IDEA) Part B provides federal funding to researchers reviewing the educational records of 13 students
assist school districts in providing necessary resources to with complex needs overwhelmingly reported greater suc-
educate students with disabilities.22 Key to implementation cess for students engaged in inclusive settings.32 However,
of this law is the requirement for students to be educated the researchers pointed out that training and support for
in the LRE.22 Education alongside healthy peers is consid- interprofessional teams must be provided during the process.
ered the LRE, making it a priority to provide supportive From the perspectives of interprofessional teams who serve
services in the regular classroom to the greatest extent pos- school-aged children with complex needs, it has also been
sible. Alternative settings are considered only if the severity reported that professionals believe these children can be
of the disability renders this option impossible, even with successfully educated in inclusive settings with appropriate
supports. According to the US Department of Education, supports.33
most children with severe disabilities who require multiple
types of special education services are educated primarily
in self-contained classrooms.22 This finding indicates that
school districts continue to struggle with providing adequate
ADVOCACY:
supports to educate children with multiple needs in inclusive EMPOWERING CHILDREN AND
settings.
Parents have reported educational issues as some of THEIR FAMILIES
the most stressful aspects of raising a child with special
needs.23,24 Parents of children with special needs in segre- All professionals have the desire to empower children
gated and integrated environments have reported positive and their families to become self-advocates.34 As noted in
and negative aspects of both.25 In one study, 262 mothers of the ICF Model, participation at home, in school, and in the
children placed in either inclusive or specialized placements community involves an awareness of the health conditions,
were interviewed by researchers.25 Mothers of children in both mental and physical, that play a role in an individual’s
inclusive settings felt certain that their children’s social ability to perform age-appropriate activities. Barriers to
needs were being met but sometimes felt the educational full participation are more easily addressed by support
program was not as tailored to their children’s specific needs. services provided in educational settings, but these are not
 Providing Support for Children 5 to 21 Years in the Educational Setting 145

necessarily available to students and their families as they programming opportunities arise, pediatric therapists have
leave educational settings. Developing advocacy skills in the responsibility to work with the special education team
parents begins during EI and ECSE. Children’s self-advo- and administrators to ensure that the needs of all are taken
cacy can be developed as early as elementary school. Ways into consideration.
that the interprofessional team can help students develop
self-advocacy skills include the following35:
• Writing down students’ ideas, questions, and concerns TRANSITION SERVICES
before the IEP meeting
• Helping students rehearse what they want to say in the The National Association of Special Education Teachers
IEP meeting (NASET) describes the transition from high school:
• Teaching students to introduce themselves properly Depending on the nature and severity of the disability,
• Talking to students about their interests, strengths, and special education professionals and parents may play
desires for the future more of an ongoing role in the child’s life even after
• Teaching students to explain their disability to class- he or she leaves secondary education. Historically,
mates, teachers, and others parents and their children have spent years actively
involved in Individual Educational Plan (IEP) devel-
• Encouraging students to ask for explanations if they
opment and meetings, transitional IEP (ITEP) devel-
don’t understand something
opment, and Committee on Special Education (CSE)
• Reviewing what the team has agreed to at the end of meetings concerning educational and developmental
the meeting welfare. Depending upon the mental competence (the
With their unique training and knowledge, physical capability to make reasoned decisions) of the child
therapists, occupational therapists, and speech-language with disabilities, some parents may have to continue to
pathologists in the educational setting have the opportunity make vital decisions affecting all aspects of their chil-
to work with the same children over extended periods of dren’s lives; they need not shy away, thinking that they
time, allowing more opportunities to help children develop are being too overprotective if they are involved in the
these self-advocacy skills.36 These efforts support a student- child’s life after the child leaves school. On the other
centered education that can lead to academic success and the hand, the parents of children not affected by dimin-
development of skills needed in adulthood. The interpro- ished mental competence should use all their energies
fessional team can also promote “Kids As Self Advocates to encourage the child’s steps toward independence.38
(KASA), a national, grassroots project created by youth with
Postsecondary goals must take into account the student’s
disabilities for youth.”37 This group offers teens and young
interests, preferences, needs, and strengths. Options avail-
adults with disabilities a forum for speaking out and sharing
able post–high school may include postsecondary education,
information.
vocational education, integrated employment (including
In addition, pediatric therapists can collaborate with supported employment), continuing and adult education,
the educational team to ensure that students have needed adult services, independent living, or community participa-
accommodations for inclusion and participation in school tion, depending upon available resources.39 School practitio-
activities. Advocacy includes providing team members with ners can aid during this transition process by compiling a list
information about current evidence-based interventions; of available resources for families, such as grants, extracur-
making recommendations and referrals for needed services ricular activities, social services, respite care for the family,
based upon the needs and goals of students, families, and assistance with navigating the health care system, and avail-
educators; supporting the acquisition of assistive technology able postsecondary options.
(AT) and durable medical equipment (DME); and commu-
For those students who intend to go on to postsecond-
nicating with other service providers in medical settings to
ary education from high school, the US Department of
ensure continuity of care.34
Education offers a website that provides vital informa-
Professionals in educational settings must engage in tion for this transition: https://www2.ed.gov/about/offices/
ongoing advocacy to meet individual student’s needs while list/ocr/transitionguide.html#introduction.40 In addition
simultaneously ensuring that federal and state laws and to offering guidance in terms of civil rights issues, the site
regulations continue to support inclusive services in schools answers common questions about the admissions process
and the community. Pediatric professionals, especially those and postadmission considerations (eg, having documenta-
aligned with professional and nonprofit organizations, are tion of disability). “Students with disabilities possess unique
well positioned to advocate for programming, policies, knowledge of their individual disabilities and should be
and decisions that impact children with disabilities in the prepared to discuss the functional challenges they face and,
educational setting. As policies are being updated and new if applicable, what has or has not worked for them in the
146 Section 9

past.”40 Keys to student success include strong self-advocacy born prematurely and diagnosed with cerebral palsy at 2
skills, a solid preparatory curriculum for postsecondary edu- years old. He was briefly enrolled in EI, then he transitioned
cation, a good understanding of the student’s own disability, to ECSE in a different state. Standardized assessment at age
self-responsibility, strong computer and self-management 4½ indicated that Narin’s fine motor and gross motor skills
skills, and gaining familiarity with the educational setting were more than 2 standard deviations below normal when
and learning expectations (eg, college visits and participa- he was enrolled in kindergarten. Narin’s parents are origi-
tion in orientation). The educational team should help stu- nally from Cambodia and are involved parents. His father is
dents with disabilities develop these key abilities linked to able to communicate in English but is sometimes difficult to
success, facilitating their transitions from high school to understand. His mother speaks and understands a little bit
postsecondary education. of English. Narin’s aunt also lives with them to assist with
The educational opportunities for growth and develop- his care and does not understand or speak English. His fam-
ment during childhood and youth are tremendous; however, ily still believes Narin will “recover” and will be a “normal”
they may be overlooked if the educational team lacks the child and therefore do not see a need to invest in new adap-
long-range perspective needed to help students successfully tive equipment. Narin is an only child.
transition from childhood to adulthood. The interprofes- The following is a summary from Narin’s ECSE team:
sional team must share discipline-specific knowledge and • Strengths: Narin is eager to come to school and is very
resources to optimize students’ educations and, ultimately, well liked by his classmates at preschool. He is very
their transitions to adulthood. talkative, but his speech is difficult to understand. He
enjoys coming to preschool and is eager to participate
in therapy sessions. He invites his classmates to be part
INTERPROFESSIONAL ACTIVITY of the group play during therapy.
• Needs: Narin has had difficulty engaging in play with
Interprofessional Care in Elementary School his classmates, circle time, and class activities. He has
difficulty with attention due to his limited postural
After reviewing Case 9-1, answer the following questions control and motor skills to engage in learning activi-
as an interprofessional team: ties. He is able to say a few words but is difficult to
1. Discuss interprofessional and discipline-specific understand. He lacks postural control in sitting and is
assessments you would recommend for this child. dependent in mobility (he is pushed in a child stroller).
2. Discuss possible SMART goals that you share with He is unable to transition from one position to another.
the teachers and family in an IEP meeting. (SMART • Preschool supports: Narin currently has no technologi-
= Specific [simple, sensible, significant], Measurable
cal support because his parents do not see the need for
[meaningful, motivating], Achievable [agreed, attain-
investing resources in any adaptive equipment or assis-
able], Relevant [reasonable, realistic and resourced,
tive technology. He requires 1:1 assistance throughout
results-based], and Time bound [time based, time
his day (eg, feeding, taking off coat, mobility, toileting,
limited, time/cost limited, timely, time-sensitive].)
transfers, fine motor skills for learning activities).
3. Describe age-appropriate therapeutic activities you
He has benefited from a supportive preschool staff,
would recommend for this educational setting.
including good follow-through with recommendations and
4. Discuss appropriate supports for the child’s IEP, encouraging Narin’s participation in all activities as much as
including assistive technology such as adaptive devices he is able. Narin has received occupational therapy, speech-
to promote functional independence. language therapy, and assistive technology services. His
elementary school is 2 stories, and the school made certain
that all of Narin’s classes were on the first floor.

Interprofessional Care in High School

Consider the recommendations you would have made
Case 9-1: A 6-year-old boy with cerebral for Narin across his elementary school years. He has since
graduated from the local elementary school and must transi-
palsy and spastic athetosis tion directly to the local high school because there are no
This new kindergartner qualifies for special education middle schools in this small town.
services at a rural elementary school. The occupational 1. Discuss interprofessional and discipline-specific
therapist, speech-language pathologist, and physical thera- assessments you would recommend for Narin.
pist are all contract service providers who are assigned to this 2. Discuss possible SMART goals41 that you share with
school 2 days per week. The new kindergartner is Narin, the teachers and family in an IEP meeting.
 Providing Support for Children 5 to 21 Years in the Educational Setting 147

3. Describe age-appropriate therapeutic activities you

would recommend for this educational setting.
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23. Kurth JA, Morningstar ME, Kozleski EB. The persistence of highly for complete mental health. Journal of Educational and Psychological
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dence disabilities. Res Prac Persons Severe Disabl. 2014;39(3):227-239. 44. Malik VS, Willett WC, Hu FB. Global obesity: trends, risk factors and
24. Brown J, Rodger S. Children with disabilities: Problems faced by policy implications. Nature Reviews Endocrinology. 2013;9(1):13-27.
foster parents. Children and Youth Services Review. 2009;31(1):40-46. 45. National Research Council (US) and Institute of Medicine (US)
25. Leyser Y, Heinze A, Kapperman G. Stress and adaptation in families Committee on the Prevention of Mental Disorders and Substance
of children with visual disabilities. Families in Society: The Journal of Abuse Among Children, Youth, and Young Adults: Research Advances
Contemporary Social Services. 1996;77(4):240-249. and Promising Interventions. Preventing Mental, Emotional, and
26. Guralnick MJ, Connor RT, Hammond M. Parent perspectives of peer Behavioral Disorders among Young People: Progress and Possibilities.
relationships and friendships in integrated and specialized programs. Washington, DC: National Academies Press; 2009. https://www.ncbi.
Am J Ment Retard. 1995;99(5):457-475. nlm.nih.gov/books/NBK32775
27. Beadle‐Brown J, Murphy G, Wing L. The Camberwell cohort 25 years 46. Ogden CL, Carroll MD, Curtin LR, Lamb MM, Flegal KM.
on: Characteristics and changes in skills over time. J Appl Res Intellect Prevalence of high body mass index in US children and adolescents,
Disabil. 2006;19(4):317-329. 2007–2008. JAMA. 2010;303:242-249.
28. Hendrickson JM, Smith CR, Frank AR, Merical C. Decision mak- 47. Snakenborg J, Van Acker R, Gable RA. Cyberbullying: Prevention
ing factors associated with placement of students with emotional and and intervention to protect our children and youth. Preventing School
behavioral disorders in restrictive educational settings. Education and Failure: Alternative Education for Children and Youth. 2011;55(2):88-95.
Treatment of Children. 1998;21:275-302. 48. Tangen D, Campbell M. Cyberbullying Prevention: One Primary
29. Smart M. Transition planning and the needs of young people and School’s Approach. Australian Journal of Guidance and Counselling.
their carers: the alumni project. British Journal of Special Education. 2010;20(02):225-234.
2004;31(3):128-137. 49. Collins CL, Fletcher EN, Fields SK, et al. Neck strength: a protective
30. Myklebust JO, Båtevik FO. Earning a living for former students with factor reducing risk for concussion in high school sports. J Prim Prev.
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Journal of Special Needs Education. 2009;24(2):203-212. 50. Navarro RR. Protective equipment and the prevention of concussion-
31. Fisher M, Meyer LH. Development and social competence after two what is the evidence? Curr Sports Med Rep. 2011;10(1):27-31.
years for students enrolled in inclusive and self-contained educational 51. Arthur MW, Hawkins JD, Pollard JA, Catalano RF, Baglioni Jr AJ.
programs. Res Prac Persons Severe Disabl. 2002;27(3):165-174. Measuring risk and protective factors for use, delinquency, and other
32. Camargo SP, Rispoli M, Ganz J, Hong ER, Davis H, Mason R. A adolescent problem behaviors: The Communities That Care Youth
review of the quality of behaviorally-based intervention research to Survey. Eval Rev. 2002;26(6):575-601.
improve social interaction skills of children with ASD in inclusive set- 52. Koo HJ, Kwon JH. Risk and protective factors of Internet addic-
tings. J Autism Dev Disord. 2014;44(9):2096-2116. tion: a meta-analysis of empirical studies in Korea. Yonsei Med J.
33. Hunt-Berg M. The Bridge School: Educational inclusion outcomes 2014;55(6):1691-1711.
over 15 years. Augment Altern Commun. 2005;21(2):116-131. 53. Centers for Disease Control and Prevention. School Violence: Risk
34. Soto G, Müller E, Hunt P, Goetz L. Critical issues in the inclusion and Protective Factors. Centers for Disease Control and Prevention
of students who use augmentative and alternative communica- Web site. https://www.cdc.gov/violenceprevention/youthviolence/
tion: An educational team perspective. Augment Altern Commun. schoolviolence/risk.html. Published February 10, 2015. Accessed
2001;17(2):62-72. February 19, 2017.
35. Pacer Center. How you can help your child learn to be a good self- 54. Centers for Disease Control and Prevention. School Connectedness:
advocate. Pacer Center Web site. http://www.pacer.org/parent/php/ Strategies for Increasing Protective Factors among Youth. Centers
PHP-c95.pdf. Accessed February 16, 2017. for Disease Control and Prevention Web site. https://www.cdc.
36. American Physical Therapy Association. Vision statement for the gov/healthyyouth/protective/pdf/connectedness.pdf. Published 2009.
physical therapy profession and guiding principles to achieve the Accessed February 20, 2017.
vision. American Physical Therapy Association Web site. http://www. 55. Gambone MA, Klem AM, Summers JA, Akey TM, Sipe CL. Turning
apta.org/Vision/. Updated September 9, 2015. Accessed December 12, 2017. the Tide: the Achievements of the First Things First Education Reform
37. Kids as Self-Advocates. http://fvkasa.org/index.php. Accessed in the Kansas City, Kansas Public School District. Philadelphia, PA:
February 17, 2017. Youth Development Strategies, Inc; 2004.
38. Allison VL, Nativio DG, Mitchell AM, Ren D, Yuhasz J. Identifying 56. Florida Department of Education. Section 2: Identification of Risk
symptoms of depression and anxiety in students in the school setting. and Protective Factors. Florida Department of Education Web site.
The Journal of School Nursing. 2014;30(3):165-172. http://www.f ldoe.org/core/fileparse.php/7771/urlt/0084829-sec2.
pdf. Accessed February 20, 2017
Section 10
Providing Interprofessional Medical Care
for Children and Adolescents
Brandi Dorton, DPT; Stephanie Orr, PT, DPT, PCS; Joan Delahunt, OTD, MS, OTR/L;
Lynn Drazinski, MA, CCC-SLP; and Catherine Rush Thompson, PT, PhD, MS

behavioral, and motor milestones, emphasizing the child’s

OVERVIEW return to daily activities. Examples of conditions seen in
both educational and health care settings include Down
In the health care setting, pediatric therapists play an syndrome, cerebral palsy, autism spectrum disorder (ASD),
integral role in the management of children and adoles- attention deficit hyperactivity disorder (ADHD), muscular
cents with acute and chronic medical conditions. Although dystrophy, and spinal muscular atrophy, among others.
many children with medical conditions are eligible for early However, children with pathologies needing medical diag-
intervention (EI) and school-based programs discussed ear- noses and acute interprofessional care are typically managed
lier in this book, the focus of interprofessional care differs best in a clinic, hospital, or rehabilitation setting where
based on practice setting. For programs offered through the the focus is on stabilizing the health condition, recovering
Individuals with Disabilities Education Act (IDEA) Parts B function, and building the needed skills and endurance to
and C (as described in Sections 7, 8, and 9), the interprofes- resume regular activity.1-3 For example, physical therapists,
sional focus of care is on child-centered and family-centered occupational therapists, and speech-language pathologists
interventions to enhance parenting skills and increase par- work with children and adolescents with acute traumatic
ticipation in daily life activities in the home and community, brain injuries and traumatic spinal cord injuries until they
as well as providing needed supports to help children with are ready to return home and engage in their daily routines
special needs learn in the least restrictive educational (LRE) at school, leisure and/or work, and home.
settings. Within the medical setting, pediatric therapists are
Pediatric therapists in health care settings also serve a
clinicians who work in partnership to create a collaborative
wide range of medical needs related to: (1) surgical manage-
plan of care for each child (including a discharge plan) based
ment of conditions (eg, pre- and post-procedure care for
upon health outcomes rather than educational outcomes.
posterior spinal fusions and postoperative care for bone frac-
Clinicians in health care settings work collaboratively to tures); (2) management of complications from congenital
manage a wide variety of conditions affecting developmental,

Thompson CR. Pediatric Therapy:

An Interprofessional Framework for Practice (pp 149-163).
- 149 - © 2018 SLACK Incorporated.
150 Section 10

diagnoses (eg, bronchopulmonary dysplasia and congenital

heart defects); (3) reducing conditions related to prolonged
SCREENING AND EVALUATION
hospitalization; (4) providing intensive care during the onset
of new conditions, such as stroke, conversion disorder, or In medical settings, physicians will oftentimes refer
chronic pain; (5) discharging patients from medical care; their pediatric patients to physical therapists, occupational
and (6) supporting the child and family during terminal therapists, and speech-language pathologists to determine
illness.1-3 if their specialized services are warranted. After receiving a
referral, each therapist will begin a screening and evaluation
Physical therapists, occupational therapists, and speech-
process to determine the level of need and corresponding
language pathologists are responsible for screening, evalu-
plan of care. Therapists in the health care setting perform a
ation, and developing a plan of care to assist children in
thorough chart review of the patient’s medical history and
restoring their prior level of function, reaching their full
an interview with the pediatric patient (if appropriate) and
potential with new deficits, or preventing further decline
family as part of the assessment of the child’s current skills,
in function. Using a collaborative team approach, pediatric
developmental history, home setting, interests and activities,
therapists work together to determine the needs of a patient,
and specific health concerns. With this foundational infor-
equipment or adaptations required for optimal function and
mation, pediatric therapists have the ability to collaborate
mobility at home and integration in the community, and
during the evaluation process, providing more coordinated
the appropriate discharge plan for services after an inpatient
services and an integrated plan of care.
stay.1-3
Often the initial screening or evaluation will occur with
multiple disciplines present, as in other practice settings.
Multidisciplinary evaluations are commonly used to deter-
AGE-SPECIFIC RISK FACTORS mine plans of care for various types of pediatric care, such
as burn care, pain management, and management of feed-
Therapists each contribute to the screening process for ing disorders.5,6 During the initial assessment, disciplines
risk factors and ensure that they are addressed quickly dur- work together to ask questions to understand the patient’s
ing an inpatient hospitalization. Risk factors are managed prior level of function in all areas. This information assists
by evidence-based intervention (eg, therapeutic positioning the team in determining the most appropriate plan of care,
to protect skin integrity, preventing contractures or loss including the expected duration of treatment to regain these
of range of motion, avoiding abnormal postures that may prior skills.7,8 A child’s communication style and cognitive
develop after a neurological insult, and encouraging engage- status are important to all team members, as these factors
ment in healthy behaviors). Being cognizant of an indi- critically impact how all disciplines will engage the pediatric
vidual’s communication style is also vitally important for patient most effectively.
understanding a patient’s wants and needs during her care. Although some areas of assessment overlap, it is essential
It is crucial to be aware of age-specific risk factors in the that pediatric therapists recognize and trust each other’s
acute care setting to best serve the needs of children and expertise and communicate thoroughly to ensure that
their families. Whereas some children may have risk factors referrals are appropriate and sufficiently comprehensive.
addressed in EI and educational settings, children entering Effective interprofessional collaboration between pediatric
medical care without prior special education needs may not therapists can increase efficiency and reduce costs of care.9
have had prior medical attention to these issues. Health As outlined in Section 1, interprofessional care relies on role
screenings in all settings can help prevent future disability. clarification, child-/family-/school-centered care, interpro-
Understanding typical human growth and development fessional communication, conflict resolution, team func-
(Section 4) will also help provide a framework for typical tioning, and collaborative leadership.
behaviors to expect in terms of developmental milestones Listed in Table 10-2 are examples of common areas
for each age group. Table 10-1 lists recommendations for that all disciplines may evaluate together during the initial
pediatric health and wellness in medical settings. interaction with the pediatric patient (eg, attention, arousal,
Pediatric patients who are immobile due to new or pre- cognition, sensorimotor function, pain, and cardiopulmo-
existing conditions, regardless of their age, are at high risk nary function). This areas of evaluation are augmented by
for loss of skin integrity, loss of range of motion/contrac- discipline-specific tests and measures deemed necessary by
tures, dislocations, and respiratory complications due to the clinicians to complete a comprehensive plan of care that
prolonged positioning.4 addresses the pediatric patient’s specific needs. Although not
 Providing Interprofessional Medical Care for Children and Adolescents 151

TABLE 10-1
RECOMMENDATIONS FOR PEDIATRIC HEALTH AND WELLNESS
AGE RECOMMENDATIONS FOR PEDIATRIC HEALTH AND WELLNESS
Neonate and • Monitoring growth and development
infant (birth • Assessing anthropometrics: length/height and weight, head circumference, weight for
to 1 year) length, and body mass index (making a referral if the child is at risk for failure to thrive)
• Assessing/reviewing vital signs, including cardiorespiratory function
• Assessing neurodevelopmental skills, including screening for autism
• Assessing behavior of infant and mother (related to postpartum depression)
• Assessing sensory systems: vision and hearing
• Instructing families in health promotion
• Introducing the Back to Sleep Program and Prone to Play Program
• Educating about appropriate sensory stimulation and decreasing noxious stimulation
• Educating about parental/caregiver bonding opportunities
• Suggesting therapeutic positioning throughout day (eg, to prevent torticollis)
• Progressing feeding by breast or bottle to finger food
Toddler • Monitoring growth and development
(1 year to • Instructing families in health promotion
3 years) • Ensuring safety in sleep and play environments
• Monitoring developmental skills to discern decline or lack of progression
• Addressing decreased or absent play exploration with toys and books
• Addressing delays with language development
• Noting attachment to family members or interactions with peers
• Addressing delays with self-care skill development (dressing, toileting, feeding, bathing,
and grooming)
Child • Monitoring growth and development
(3 to 10 years) • Screening for mental health concerns, such as depression or the need for professional
psychological support
• Monitoring for safety awareness during learned mobility
• Preventing muscle atrophy from prolonged bed rest
• Preventing loss of range of motion
• Decreasing dependence on adult for self-care needs (dressing, eating, grooming, bathing)
• Addressing low interest in social opportunities
• Monitoring decreased participation with leisure opportunities
• Noting a decline or lack of progression in academic skills
Adolescent • Monitoring growth and development, as needed
(11 to 21 years) • Watching for signs of drug use and abuse (eg, sudden change in behavior, mood swings,
irritable and grumpy and then suddenly happy and bright, withdrawal from family
members, careless about personal grooming, loss of interest in hobbies, sports and other
favorite activities, changed sleeping pattern; up at night and sleeping during the day, red
or glassy eyes, sniffling or runny nose)
• Education about sexually transmitted diseases, if appropriate
• See recommendations for Child
Adapted from American Academy of Pediatrics. AAP Schedule of Well-Child Visits. HealthyChildren Web site. https://www.healthychildren.
org/English/family-life/health-management/Pages/Well-Child-Care-A-Check-Up-for-Success.aspx. Published June 27, 2017. Accessed
December 11, 2017 and American Academy of Pediatrics. Recommendations for Preventive Pediatric Health Care. American Academy of
Pediatrics Web site. https://www.aap.org/en-us/documents/periodicity_schedule.pdf. Published February, 2017. Accessed on December 11, 2017.
152 Section 10

TABLE 10-2
EXAMPLES OF INTERPROFESSIONAL AREAS OF EVALUATION
CATEGORY DESCRIPTION OF INTERPROFESSIONAL ASSESSMENTS
Body systems Neurological structures and functions are assessed (eg, cognition, cranial and peripheral
nerve function, reflexes, and motor control for functional skills). Cognition abilities,
including attention and arousal, are assessed subjectively during patient/therapist
interaction. The child s ability to understand is important for communication during
instruction and education in therapy. As the fifth vital sign (in addition to temperature, blood
pressure, pulse rate, and respiration rate), pain should be monitored each visit. Pain at rest and
with activity is important to note to determine how the patient will tolerate future
therapy sessions.
Cardiopulmonary structures and functions are assessed (eg, skin color, breathing patterns,
heart rate, respiratory rate, oxygen saturation, and edema) at rest, during therapy sessions, and
following activities.
Integumentary structures and functions are assessed (eg, skin appearance, presence of
wounds, bruising, rashes, and/or callus formation), especially related to the use of splints,
orthotics, or other external pressures.
Musculoskeletal structures and functions are assessed (eg, strength, range of motion, and
endurance for performing functional motor functions).
Other body structures and functions (eg, gastrointestinal, genitourinary, limbic, endocrine) are
monitored to insure the child s safety, comfort, and health.
Activities: Developmental skills (gross motor, fine motor, communication, feeding, emotional,
developmental psychosocial skills) and play activities are observed, assessed, and integrated into therapeutic
skills and play activities that prepare the child for functional independence after discharge.
activities
Environmental Interprofessional teams assess and recommend appropriate adaptations, assistive devices,
and personal and environmental modifications to enhance function, as needed. Personal factors, including
factors motivation, adherence to recommendations, and lifestyle living habits, are used for
personalizing care.
Disability Goals are designed toward restoration of function, reducing disability and promoting
improved quality of life following hospital discharge.
Adapted from American Academy of Pediatrics. HealthyChildren Web site. https://www.healthychildren.org/English/Pages/default.
aspx; American Academy of Pediatrics. AAP Schedule of Well-Child Care Visits. HealthyChildren Web site. https://www.healthychildren.
org/English/family-life/health-management/Pages/Well-Child-Care-A-Check-Up-for-Success.aspx; and American Academy of Pediatrics.
Recommendations for Preventive Pediatric Health Care. American Academy of Pediatrics Web site. https://www.aap.org/en-us/docu-
ments/periodicity_schedule.pdf.

exhaustive, Table 10-3 provides examples of discipline-spe-

cific tests used to further examine common areas of concern.
EVIDENCE-BASED STRATEGIES FOR
The subjective interview is typically the most convenient PREVENTATIVE CARE
time for eliciting each patient’s and family’s goals. The team
may assist the patient and family in determining these goals Patients and their families may encounter pediatric thera-
based on information related to the home environment, pists for needs other than gaining new skills and function.
school environment, and the child’s prior level of function. For example, clinicians play a critical role in implementing
Once goals have been established, the interdisciplinary team support for patients and their families, preventing second-
works together to ensure progress is made toward the goals ary complications, and easing challenges with daily care
vital to the pediatric patient and family. through family education.
 Providing Interprofessional Medical Care for Children and Adolescents 153

TABLE 10-3
EXAMPLES OF DISCIPLINE-SPECIFIC TESTING USED IN HOSPITAL-BASED SETTINGS
DISCIPLINE AREA OF EXPERTISE EXAMPLES OF DISCIPLINE-SPECIFIC TESTS
Speech- Language delay/disorder Clinical Evaluation of Language Fundamentals (CELF)
language Speech sound disorder Goldman Fristoe Test of Articulation
pathology
Feeding disorder Modified Barium Swallow
Cognition Woodcock-Johnson Test of Cognitive Abilities
Literacy delay/disorder Phonological Awareness Test
Physical Structural integrity Anterior/posterior drawer test
therapy Respiratory function Incentive spirometry
Fitness Fitness Gram
Gait Dynamic Gait Index
Balance Pediatric Balance Scale
Endurance 6-minute walk test
Occupational Handwriting Evaluation Tool of Children s Handwriting
therapy Play and leisure Knox Preschool Play Scale
Self-care Assessment of Motor and Process Skills (AMPS)
Sensory processing Sensory Integration and Praxis Test
Visual perceptual Motor-Free Visual Perception Test
See Appendix B for a more comprehensive list of pediatric tests and measures with references.

Developmental/Behavioral Screenings result of that medical condition or from unrelated causes.

Pediatric therapists provide patient and family education to
Typically, families provide preventive care for their prevent secondary complications, including, but not limited
children through routine medical checkups. For patients to, the following:
with medical diagnoses, preventative care typically includes • Maintenance of range of motion to avoid joint con-
periodic developmental or behavioral screenings to detect tractures leading to pain, impaired mobility, and/or
potential developmental delays and/or clinical manifesta- difficulties with positioning in equipment;
tions of newly developing health problems. These screenings
can include standardized tests or observational assessments • Weight bearing and positioning for bone health and to
by pediatric therapists. Early screening of infants, children, promote proper joint development and alignment;
and adolescents can lead to more timely referrals and expe- • Therapeutic positioning recommendations for skin
dite the process of the patient receiving quality of care in the integrity, prevention of abnormal posture, tone manage-
appropriate settings.10,11 ment, vestibular system input, and vital body functions
(including digestion and lung/cardiac health) to prevent
Patient and Caregiver Education secondary complications in children/adolescents with
chronic diagnoses;
Medical conditions, new or existing, may present the
• Environmental modifications, such as visual schedules
need for a caregivers’ attention to a variety of issues to pro-
to promote increased participation in daily activities of
mote the child’s health outcomes and prevent secondary
self-care;
complications for their children with chronic conditions.
Secondary complications are clinical manifestations that • Adaptive equipment for feeding, dressing, bathing, and
develop in the course of a primary diagnosis, either as a toileting; and
154 Section 10

• Adaptations for activities to promote language, cogni-

tive, social, and academic development.
EVIDENCE-BASED STRATEGIES FOR
There is no one-size-fits-all prescription for children MANAGEMENT OF COMMON ACUTE
and youth, so the interprofessional team must work col-
laboratively with the family to determine the interventions CONDITIONS
and strategies most likely to yield successful outcomes.
Professionals must be good listeners to capture what the The management of acute medical conditions of pediatric
family members value and provide a strong rationale for patients often includes interventions provided by occupa-
each intervention to gain patient and family endorsement. tional therapists, physical therapists, and speech-language
pathologists. These services are usually provided in the
Promotion of Health and Wellness inpatient setting throughout the duration of care. A pedi-
atric patient may receive a combination of individual and
Health and wellness is important to every child, with cotreatment sessions to achieve goals set by the team and
or without disability. In addition to screening for age- family. Treatments by the interdisciplinary team address
related risk factors discussed earlier in this book, pediatric the increased physical, social, and emotional needs of the
therapists need to consider additional potential risk factors patient, while conserving the child’s energy for participa-
associated with specific medical diagnoses. These risk fac- tion throughout the day.15,16 Regardless of diagnosis, the
tors, if addressed early, can prevent associated secondary interdisciplinary team will work together prior to discharge
complications. For this reason, pediatric therapists should to determine the equipment needed for home, recommenda-
recommend appropriate health promotion strategies as soon tions for continued therapies, and family training/education
as possible. For example, children who have developmental needs. Examples of acute medical conditions that require
disabilities often have limited physical activity and are at interprofessional care include traumatic brain injury, spinal
an increased risk for obesity. Health promotion strategies cord injury, and deconditioning secondary to some acute
for this population may include increasing physical activity medical conditions involving prolonged hospitalization and
through adaptive sports, participation in Special Olympics, immobilization. Listed in Table 10-4 are common acute
weight management to prevent difficulty with mobility, and conditions typically addressed by the interdisciplinary team.
lifestyle habits (including diet) to reduce additional risks The interprofessional team works together to ensure that
of disability and chronic disease. The American Physical appropriate preventive care is implemented consistently as
Therapy Association’s Pediatrics Fact Sheet entitled The part of the patient’s overall management.
Role and Scope of Pediatric Physical Therapy in Fitness,
Wellness, Health Promotion, and Prevention provides exercise
considerations addressing both strength and aerobic activi-
ties for children with and without disability.12 Similarly,
EVIDENCE-BASED STRATEGIES FOR
speech-language pathologists promote the development and
maintenance of effective personal and professional commu-
MANAGEMENT OF COMMON CHRONIC
nication in individuals both with and without a communi- CONDITIONS
cation disorder. The American Speech-Language-Hearing
Association (ASHA) provides resources and activities related A relationship with a team of pediatric therapists (wheth-
to communication wellness and the prevention of commu- er short- or long-term) begins once an infant, child, or
nication disorders.13 The American Occupational Therapy adolescent is diagnosed with a chronic condition. This team
Association (AOTA) emphasizes health promotion through of dedicated therapists will play a significant role in the
the inclusion of health and wellness as one of the 7 identified management of each patient’s condition. Intervention may
areas of practice for occupational therapists.14 Occupational occur intermittently, addressing changes in the individual’s
therapists can create health-promoting play activities for medical status, growth, or development from the time of
children to enhance physical well-being while in medical onset of the chronic condition until management becomes
care. Using evidence-based health promotion strategies part of the child’s daily routines in life. Although the condi-
increases the likelihood of accomplishing health outcomes tion may initially require therapy in an acute care setting,
that are sustainable across the child’s lifespan. management will oftentimes continue through outpatient
care in a hospital clinic or outpatient setting. Pediatric thera-
pists provide interdisciplinary treatment for a wide range of
chronic conditions, including developmental or behavioral
 Providing Interprofessional Medical Care for Children and Adolescents 155

TABLE 10-4
EXAMPLES OF ACUTE CONDITIONS INVOLVING INTERPROFESSIONAL COLLABORATION
ACUTE INTERVENTION PURPOSE
CONDITION
Brain injuries Therapeutic Prevent skin breakdown, manage tone, encourage cardiovascular
positioning function through antigravity postures (while ensuring spinal precautions
are followed)
Joint mobility Maintain range of motion and prepare for active movement; using
pressure-relief ankle-foot orthoses and splints to maintain safe
joint positioning
Sensory stimulation Orient a patient to her environment, activate increased motor responses
using olfactory, vestibular, tactile, proprioceptive, and auditory stimulation
Feeding Increase tolerance of food texture and amount of intake, monitor for safety
of suck/chew/swallow, position for safety, and advance independence
Improved strength Insure adequate head, trunk, and extremity motor control (postural control)
and motor control and endurance for functional activities.
Progressive mobility Encourage movement, beginning with bed mobility, supported sitting,
transfers and walking, using assistance, body weight support, treadmill
training, aquatic therapy and/or functional electrical stimulation
Adaptive equipment Facilitate functional activities, using customized adaptive devices, as needed
Patient and family Assist with home care at the patient s level at discharge
education
Spinal cord Therapeutic Promote skin integrity, manage muscle tone, and provide breath support;
injury (acute positioning progressive upright positioning in wheelchair or tilt table; use of abdominal
phase) binder, lower extremity compression garments
Joint mobility Maintain range through passive exercises, positioning or use of splints;
obtain spinal precautions from the physician
Communication Develop functional communication (possibly needing augmentative
or alternative communication) through promoting breath support and
providing strategies for voice production and improved intelligibility
Patient and family Reduce the risk of secondary complications (eg, pressure sores,
education orthostatic hypotension, autonomic dysreflexia, and temperature
dysregulation) through providing pressure relief strategies, instructing in
safe transfers, managing bowel and bladder, and carefully monitoring vitals
Spinal cord Mobility Promote mobility, including mat/bed mobility, transfers, wheelchair
injury mobility, advanced wheelchair skills, and gait training using body weight
(rehabilitation support treadmill training, aquatic therapy, and functional electrical
phase) stimulation, as needed
Balance training Encourage development of balance during activities of daily living; ring and
short sitting
Feeding Progress feeding/eating skills for increased independence
Self-care Advance skills in independent grooming, dressing, bathing, and
management of bowel/bladder
Communication Provide strategies for improved intelligibility
Patient and family Prepare family for assisting with home care at patient s level at time of
education discharge
(continued)
156 Section 10

TABLE 10-4 (CONTINUED)

EXAMPLES OF ACUTE CONDITIONS INVOLVING INTERPROFESSIONAL COLLABORATION
ACUTE INTERVENTION PURPOSE
CONDITION
Deconditioned Functional Encourage functional mobility (as possible), taking into account (1)
patient from mobility current developmental level, (2) functional mobility, (3) prior level of
prolonged function, (4) range of motion, (5) tolerance to activity, (6) endurance,
hospitalization (7) vital signs, and lines/tubes (chest tubes, extracorporeal membrane
oxygenation catheters, intravenous access, peripherally inserted central
catheter lines) during assessment and intervention
Self-care Facilitate self-care participation through use of adaptive equipment for
feeding, bathing, grooming, dressing, and toileting
Communication Support communication to advocate for individual needs; determine the
need for augmentative or alternative communication, as needed
Orthopedic Functional Encourage mobility (eg, bed mobility, transfers, gait, stair management),
conditions, mobility taking into account restrictions on movement and weight bearing,
injuries, and through exercises to prevent loss of strength/endurance and gait
surgeries training and stair management with appropriate assistive device(s) or
modifications, as needed
Self-care Facilitate increased independence with dressing, bathing, toileting, and
grooming, using modifications for activities of daily living, including
adaptive equipment (eg, a reacher, grab bar, or bath chair) depending on
the child s unique need
Patient and family Promote family knowledge about the level of assistance required,
education modifications to home, and strategies for function in the community
through education and demonstration, as needed
Adapted from Strenk M. Early physical therapy/occupational therapy intervention for traumatic spinal cord injury. Cincinnati Children s
Web site. http://www.cincinnatichildrens.org/svc/alpha/h/health-policy/best.htm. Published September 5, 2014. Accessed December 28,
2017; International Brain Injury Association. Evaluation and treatment planning in children with TBI. International Brain Injury Association
Web site. http://www.internationalbrain.org/articles/evaluation-and-treatment-planning-in-children-with-tbi/. Published December 10,
2012. Accessed February 12, 2017; University of Rochester Medical Center. The Pediatrics Orthopedic Team. University of Rochester Medical
Center Web site. https://www.urmc.rochester.edu/encyclopedia/content.aspx?contenttypeid=90&contentid=P02775. Accessed February
12, 2017; and Wieczorek B, Burke C, Al-Harbi A, Kudchadkar SR. Early mobilization in the pediatric intensive care unit: a systematic review. J
Pediatr Intensive Care. 2015;2015:129-170.

diagnoses, torticollis, scoliosis, chronic pain, cerebral palsy, consent presents legal and ethical issues for pediatric clini-
congenital heart conditions, oncological diagnoses, muscu- cians. “Parental permission and childhood assent is an active
lar dystrophy, cystic fibrosis, and sickle cell anemia, among process that engages patients, both adults and children, in
others. Table 10-5 lists common chronic medical conditions their health care.”17 While a free appropriate public educa-
and examples of interprofessional therapeutic interventions. tion (FAPE) in school settings requires consent through the
Individualized Education Program (IEP) process, medical
care requires specific consent for medical management
LEGAL AND ETHICAL ISSUES of pediatric conditions. Again, family-centered care is a
cornerstone of pediatric therapy across practice setting, as
The same ethical and legal issues described in earlier discussed in earlier sections. Other legal and ethical issues
sections of the book apply to care for children and their related to medical care include providing prognostic infor-
families in medical settings. In addition, providing medical mation, maintaining patient confidentiality related to a
services to pediatric patients under the legal age of medical child’s medical condition and management, and providing
end-of-life care.
 Providing Interprofessional Medical Care for Children and Adolescents 157

TABLE 10-5
EXAMPLES OF CHRONIC CONDITIONS INVOLVING INTERPROFESSIONAL COLLABORATION
CHRONIC EXAMPLES OF PURPOSE
CONDITION TREATMENTS
Developmental Assessment and Facilitate development of functional skills (fine and gross motor, self-care,
or behavioral intervention communication, play and leisure, visual motor and visual perceptual,
diagnoses sensory and social-emotional) using individual or small-group
intervention targeting specific needs and shaping behavior
Torticollis Range of Promote head and neck movement and function related to
motion active/passive range of motion and postural, facial, and cranial
asymmetries through stretching, movement, and positioning
Therapeutic Facilitate developmental milestones through active head/neck
positioning movements in prone and side-lying
Parent Educate parents on positioning and stretches to increase neck range of
education motion for participation in play and sleep
Scoliosis Stretching Promote postural alignment and flexibility through stretching
Bracing Align posture externally using postural supports (eg, a thoracolumbosacral
support), with ongoing monitoring and education about orthotic use
Self-care Engage in self-care in daily activities (dressing, bathing, toileting, and
grooming) through increased use of arms and adaptive equipment,
as needed
Parent Educate family on energy conservation and orthotic use and maintenance
education
Chronic pain Assessment Determine possible causes of chronic pain, including range of motion,
strength, balance, endurance, and functional limitations
Physical Increase physical conditioning through aerobic activity, including
conditioning therapeutic exercise/activity and aquatic therapy
Self-care Promote self-care by addressing limitations in activities of daily living that
are restricted by pain
Cerebral palsy Range of Maintain range of motion and joint mobility through passive and active
motion range of motion, strengthening, casting/splinting, orthotics, and
constraint-induced movement therapy
Functional Encourage mobility through gait training, body weight‒supported
mobility treadmill training, neurodevelopmental therapy, and aquatic therapy;
ensure rehabilitation post-orthopedic surgeries (eg, crouch gait surgery or
dorsal rhizotomy)
Self-care Promote independence in self-care (dressing, bathing, toileting, and
grooming) through modifications, as needed
Feeding Promote independent feeding and healthy growth through
feeding strategies
(continued)
158 Section 10

TABLE 10-5 (CONTINUED)

EXAMPLES OF CHRONIC CONDITIONS INVOLVING INTERPROFESSIONAL COLLABORATION
CHRONIC EXAMPLES OF PURPOSE
CONDITION TREATMENTS
Congenital Assessment and Promote developmental skills, increasing endurance and functional
heart conditions intervention mobility (as tolerated with impairments associated with heart condition)
Physical con- Promote physical conditioning and mobility through aerobic activity to
ditioning and progress toward prior level/function or progression in developmental skill
mobility level, monitoring vital signs throughout interventions and modifying
activity (as necessary) for energy conservation
Feeding Monitor feeding skills as related to intake and nutritional status
Oncological Assessment and Encourage participation in daily activity, addressing strength, balance,
diagnoses intervention coordination, aerobic endurance, and motor skills while reducing
infection risk
Range of Monitor and manage ankle strength due to risk for impairment from
motion vincristine neurotoxicity
Muscular Functional Promote mobility and prevent disuse atrophy through submaximal levels
dystrophy mobility of aerobic exercise, coordination and balance activities, aquatic therapy,
and wheelchair use (including wheelchair prescription and management),
avoiding overwork, strengthening regimes, repetitive eccentric
movements, high load, or progressive resistive activities; prevent fractures
and falls; maximize function of upper extremities
Therapeutic Promote alignment and comfort in prone-lying, wheelchair positioning,
positioning and stander
Stretching Preventing contractures/scoliosis through stretching program and casting,
orthotics and splints, knee immobilizers
Family and Educate about energy conservation, muscle conservation, transfers/body
patient mechanics, and proper equipment use
education
(continued)

Providing Prognostic Information pathologists “make a reasonable statement of prognosis, but

they shall not guarantee—directly or by implication—the
Providing prognostic information to families and others results of any treatment or procedure.”20 These guiding
about therapeutic outcomes can be challenging. Developing standards are particularly applicable in the medical setting,
a prognosis is aided by current evidence-based research and where conditions may have a sudden onset and may not be
interprofessional collaboration. Each prognosis, based upon well understood by parents or guardians. Family education
the unique characteristics of each pediatric patient and his about the likely outcomes of therapeutic interventions can
given situation, requires sharing insights and engaging in help families cope with the many stresses of medical care.21
collaborative clinical decision making. The work of occu- Furthermore, it can help the family and the patient make
pational therapists, physical therapists, and speech-language informed decisions about future plans and the child’s return
pathologists is guided by each profession’s code of ethics, to function. Proactive care may be enhanced by the interpro-
which address the issue of providing prognostic information fessional team asking the following questions21:
carefully and truthfully. Physical therapists “shall provide 1. Which aspects of the child’s health and life are likely
truthful, accurate and relevant information and shall not to get better or worse?
make misleading representations”18; occupational thera-
2. What acute illnesses is the child likely to experience?
pists should “fully disclose the benefits, risks, and poten-
tial outcomes of any intervention”19; and speech-language
 Providing Interprofessional Medical Care for Children and Adolescents 159

TABLE 10-5 (CONTINUED)

EXAMPLES OF CHRONIC CONDITIONS INVOLVING INTERPROFESSIONAL COLLABORATION
CHRONIC EXAMPLES OF PURPOSE
CONDITION TREATMENTS
Cystic fibrosis Stretching and Maintain postural alignment through strengthening and maintaining joint
strengthening mobility and joint health; focus on maintaining erect posture and preventing
tightness in anterior musculature
Physical Promote lung and cardiac health and airway clearance techniques, which are
conditioning used in conjunction with respiratory therapy
Sickle cell Pain Manage pain through use of whirlpool sessions and transcutaneous
disease management electrical nerve stimulation
Exercise therapy Promote general health and development post-crisis
Self-care Promote independence in self-care (dressing, bathing, toileting, and
grooming) through modifications, as needed
Communication Monitor communication indicating signs of a possible stroke and ensure
effective modes of communication
Patient Educate all patients to recognize signs of infection, increasing anemia, and
and family organ failure; provide information on energy conservation techniques to
education manage daily life activities
Adapted from Aarts PB, van Hartingsveldt M, Anderson PG, van den Tillaar I, van der Burg J, Geurts AC. The Pirate group intervention
protocol: Description and a case report of a modified constraint-induced movement therapy combined with bimanual training for young
children with unilateral spastic cerebral palsy. Occup Ther Int. 2012;19(2):76-87; Audu O, Daly C. Standing activity intervention and motor
function in a young child with cerebral palsy: A case report. Physiother Theory Prac. 2017;33(2):162-172; Bushby K, Finkel R, Birnkrant DJ,
et al. Diagnosis and management of Duchenne muscular dystrophy, part 2: Implementation of multidisciplinary care. Lancet Neurol.
2010;9(2):177-189; Christensen C, Landsettle A, Antoszewski S, Ballard BB, Carey H, Pax Lowes L. Conservative management of congenital
muscular torticollis: An evidence-based algorithm and preliminary treatment parameter recommendations. Phys Occup Ther Pediatr.
2013;33(4):453-466; Dong VA, Fong KN, Chen YF, Tseng SS, Wong LM. Remind-to-move treatment versus constraint-induced movement
therapy for children with hemiplegic cerebral palsy: A randomized controlled trial. Dev Med Child Neurol. 2017;59(2):160-167; Kozlowska K,
English M, Savage B, Chudleigh C. Multimodal rehabilitation: A mind-body, family-based intervention for children and adolescents impaired
by medically unexplained symptoms. Part 1: The program. Am J Fam Ther. 2012;40(5):399-419; Maakaron JE. Sickle cell anemia treatment &
management. Medscape Web site. http://emedicine.medscape.com/article/205926-treatment. Updated July 27, 2017. Accessed March 30,
2017; Rigo M, Reiter CH, Weiss HR. Effect of conservative management on the prevalence of surgery in patients with adolescent idiopathic
scoliosis. Pediatr Rehabil. 2003;6(3/4):209-214; Sharma GD. Cystic fibrosis treatment & management. Medscape Web site. http://emedicine.
medscape.com/article/1001602-treatment. Updated July 31, 2017. Accessed March 30, 2017; and Ward R, Leitão S, Strauss G. An evaluation
of the effectiveness of PROMPT therapy in improving speech production accuracy in six children with cerebral palsy. Int J Speech Lang
Pathol. 2014;16(4):355-371.

3. What exacerbations of the existing chronic conditions 8. What decisions about major medical interventions
is the child likely to experience? (eg, major surgery) are the child and family likely to
4. What new comorbid conditions is this child likely to face?
develop? 9. What is the likely impact on the family (eg, marriage,
5. How can comorbid conditions be avoided? employment)?
6. If unavoidable, then how can one mitigate their sever- 10. What will life be like for this child in 1, 5, 10, or
ity should they occur? more years?
7. What major medical needs (eg, medications, sub-
specialty consultation, equipment) is the child likely Managing Patient and Family
to need in the future to help treat the illnesses and Confidentiality
conditions?
The Health Insurance Portability and Accountability
Act of 1996 (HIPAA) is a federal law providing patients
160 Section 10

with specific rights concerning the use and disclosure of direction of doctors, therapists can facilitate a calm environ-
their private health information.22 According to this law, ment for the child with limited medical equipment in the
pediatric therapists are required to provide every patient patient’s room using soft lighting and music, gentle range of
with a Notice of Privacy Practices at the start of treatment. motion, and positioning for comfort.24
Although the therapist is not required to obtain the patient’s
signature on the notice, she must make a good faith effort
to obtain the patient’s written acknowledgment of receiving
it. Within the medical setting, a pediatric therapist is likely
ADVOCACY
to receive a variety of requests to disclose confidential infor- As part of the interprofessional team, pediatric therapists
mation about particular patients. Examples may include a must serve as family advocates during stressful periods of
phone call from a foster parent, social worker, or attorney medical care. Advocating for the patient’s medical needs
asking the therapist to discuss the patient’s treatment plan may be necessary when the roles and responsibilities of team
or a request from a child’s parent to have a copy of the members are not clearly understood by others involved in
child’s record of therapy. Because each scenario is unique, the management of complex medical conditions. For exam-
the course of action that a therapist may follow in a given ple, a doctor specializing in oncology may not recognize the
situation depends upon the specific facts and circumstances supports that pediatric therapists can offer (see Table 10-5).
of the request and the applicable legal and ethical stan- Therapists can help the entire medical team appreciate
dards. Keeping this in mind, it is helpful to coordinate care their unique services through education and collaboration,
between therapy settings, especially when children return to potentially enhancing the overall quality of care for pediatric
the educational setting. Appropriate release of information patients served in their setting.
forms should be obtained prior to sharing any information. Advocacy is especially critical during discharge, when
the family may need referrals to community resources and
End-of-Life Care programs for support and ongoing therapy. Furthermore,
Pediatric therapists can play an important role in the collaboration between the medical team and family mem-
medical management of children and adolescents with ter- bers can ease the child’s transition back to life outside the
minal medical diagnoses. Recommendations made by thera- medical setting. Discharge planning should include resourc-
pists at earlier points in a patient’s history may be modified es for family education and social support, information
at this point to emphasize enhancing the quality of life. related to the purchase of needed equipment and services,
Regular monitoring of the patient’s status can help to facili- and resources that will best enable the child to resume daily
tate this goal.23 This care, referred to as palliative care, is: activities and participation in her roles at home, at school,
and in the community.
an approach that improves the quality of life of patients
and their families facing the problems associated with
life-threatening illness, through the prevention and
relief of suffering by means of early identification SUMMARY
and impeccable assessment and treatment of pain and
other problems, physical, psychosocial and spiritual.19 In the health care setting, pediatric therapists play an
integral role in the management of children and adolescents
Functional communication should be monitored to assure with both acute and chronic medical conditions. Clinicians
the patient’s ability to communicate for basic needs, includ- work together to create a collaborative plan of care for each
ing physical, psychosocial, and spiritual needs. Feeding skills child (including a discharge plan) based upon the patient’s
should also be monitored, and earlier recommendations may health outcomes. Whereas therapy provided in medical set-
be adjusted considering the patient’s preferences for food tings may be discipline-specific for certain aspects of care,
and drink in the context of quality of life. Positioning for the interprofessional focus of medical care is on stabilizing
comfort and sleep must be considered individually for each the health condition and on building the child’s needed
patient. Discussing ideas for relaxation strategies and coping skills and endurance to resume regular activity. During epi-
methods will be essential in facilitating healthy expression of sodes of care, the interprofessional team educates the family
the various emotions present in palliative care. about the child’s interventions and the prognosis for reach-
Creating a calming sensory environment within the med- ing desired outcomes. Finally, pediatric therapists facilitate
ical setting allows the pediatric patient and family to spend the end of medical care, whether it results in discharge or
quality time together by turning off the sound of monitors, palliative care. In all cases, the interprofessional team mem-
lowering the lights, and reducing the number of intravenous bers abide by their ethical codes and honor patient privacy,
lines and other tubes. Together with nursing, and under the as outlined in HIPAA.
 Providing Interprofessional Medical Care for Children and Adolescents 161

they meet with the therapists to help them understand the

INTERPROFESSIONAL ACTIVITY rehabilitation process.

Prognosis for Therapeutic Interventions Interprofessional Management of a Youth

1. Reflect on your professional roles as they relate to With a Spinal Cord Injury
discipline-specific and interprofessional care in a
1. Consider your knowledge and skills working with
medical setting.
patients with spinal cord injuries.
2. Read Case 10-1 and consider how this patient’s
2. Look at current evidence-based management of ado-
diagnosis would impact your interprofessional team’s
lescents with spinal cord injuries.
interactions with the child and family members.
3. Reflect on skills that are discipline-specific vs inter-
3. Find evidence-based research to support your plan of
professional skills.
care and your prognosis for this patient.
4. Consider the risk factors facing a youth returning to
4. Answer the following questions:
school postinjury.
a. What is the prognosis for this patient’s ability to
5. Review Case 10-2 as you consider the best approach
resume prior activities?
for managing this patient.
b. How would you share prognostic information
6. Answer the following questions:
with this child and family members?
a. How would the interprofessional team approach
c. What should the team consider before discharging
evaluation and treatment?
this child from services?
b. What factors would affect this patient’s outcome?
d. How could the team provide family education
regarding postoperative treatment? c. How could the team work together to ensure
that this patient is discharged safely, including
e. What are the legal and/or ethical issues that are
given needed supports (given this patient’s limited
involved in dealing with this case?
support system) and services to optimize his long-
term outcomes?

Case 10-2: A 15-year-old boy in a motor

vehicle accident
Brendan was hospitalized after his involvement in a
Case 10-1: A 7-year-old boy diagnosed with high-speed motor vehicle crash. He was diagnosed with
neuroblastoma (stage 4) traumatic complete spinal cord injury at the level of T11,
right humerus fracture, concussion/closed head injury, and
By family report, Tyler was a happy, healthy first grader right pulmonary contusion. He underwent open reduction
until very recently. His family took an extended summer and spinal cord decompression and posterior spinal fusion
vacation through several national parks, enjoying outdoor with instrumentation from the levels of T10-L2 due to
activities such as camping, hiking, swimming, and fish- his injury. He did not receive any treatment surgically for
ing. Tyler’s condition was first noted when he increasingly his right humerus fracture and was placed in a splint with
became easily fatigued and he bruised easily when hiking nonweight-bearing restrictions on the right upper extremity
with his family. Tyler also began to refuse food, complain- for the first 4 weeks of his inpatient stay. He presented with
ing of feeling full. He also reported problems urinating complete loss of motor and sensory function below T11 and
and having bowel movements. His most recent complaints was nonweight bearing on the right upper extremity, which
include diarrhea, fever, high blood pressure (causing irrita- made transfers and progression of mobility difficult. His
bility), rapid heartbeat, reddening (flushing) of the skin, and verbal interactions were atypical and suggestive of cognitive
sweating. Tyler was admitted to the children’s hospital, and deficits.
medical testing ensued.
Brendan had a complex social situation with little support
The parents were stricken by grief when tests finally and visitors throughout his hospitalization. At discharge,
revealed that he had neuroblastoma and was also diagnosed it was apparent that his caregivers’ ability to assist him at
with opsoclonus-myoclonus-ataxia syndrome or dancing home would be very limited. He lived with his father in an
eyes, dancing feet. Surgery was scheduled for later in the apartment on the second level, and his father owned a large
week. Tyler’s family wanted to explore all possible options to truck. Brendan was seen by the interdisciplinary rehabilita-
ensure Tyler’s recovery, so the medical team suggested that tion team from his acute state through his discharge from
inpatient rehab.
162 Section 10

Using Interprofessional Collaboration to Amanda’s evaluation, keeping in mind her prior reports of
agitation and exhaustion from her present medical condi-
Assist in a Patient’s Diagnosis tion and the demands of an extensive evaluation by all
1. Reflect on the typical growth and development of an team members. To reduce stress, the interprofessional team
adolescent, including the various psychosocial stress- decided to have the occupational therapist conduct the ini-
ors facing students in the high school settings. tial evaluation to begin the process of determining Amanda’s
2. Review Case 10-3 regarding a 16-year-old student needs.
who had a bicycle accident. Before the occupational therapist went to Amanda’s
3. After reading the case and using evidence-based room for the evaluation, Amanda’s nurse told her that many
resources, answer the following questions: members of Amanda’s family had been visiting for quite
some time and she felt that it was time for them to leave.
a. How should the interprofessional team approach
As the occupational therapist entered Amanda’s room, she
this patient’s evaluation and treatment?
saw many adults and children in the room talking, while
b. What is the team’s plan for patient/family educa- Amanda lay in bed crying. After introducing herself, the
tion related to understanding the possible causes of occupational therapist described her role on the rehabilita-
this patient’s signs and symptoms? tion team. Then she calmly directed the family members
c. What types of referrals or follow-up would the to leave Amanda’s room to give Amanda some time to rest.
team recommend, if any? When all the extra family members had left, the occupa-
d. What factors would most likely impact Amanda’s tional therapist interviewed both Amanda and her mother.
discharge from medical care? Her mother reported that Amanda experienced anxiety
e. How should the interprofessional team communi- prior to her traumatic head injury and was on medication
cate with the high school about why Amanda was to control her anxiety. Her mother stated that Amanda’s
missing school? anxiety had become much worse since she fell and that the
anxiety was making it much more difficult for her to do
Case 10-3: A 16-year-old girl diagnosed with anything. As the conversation continued, the occupational
therapist made the following observations of Amanda and
general anxiety disorder her room: (1) she used her right hand to hold her cell phone
Amanda’s history was normal with no evidence of any (which she kept close to her on her bed), (2) her window
mental or physical health problems until the age of 16. On blinds were open and bright sunlight was streaming into her
her 16th birthday, she was involved in a bicycle accident on room, (3) her television volume was very loud, (4) she was
her way home from school. She reportedly fell hard on her able to move her right arm and leg fairly well, (5) she moved
left side, but she did not remember if she hit her head. She her left arm and leg a little more slowly while in bed, and
was reportedly wearing a helmet at the time of her accident. (6) she closed her eyes often when she spoke. When asked
She had a couple of minor scrapes on her left leg from the about her vision, Amanda reported that she saw double and
pavement. it made her dizzy. The occupational therapist confirmed
Because she reported dizziness, she was tested for con- that closing eyes is a good strategy to manage double vision.
cussion at the time of injury at the local rural hospital, and When asked about goals for therapy, Amanda’s mother
results were negative. Since the injury 5 days ago, Amanda shared that she wanted Amanda to return home and back to
reports that her dizziness has converted to double vision, she school to finish her year, including having her as indepen-
has difficulty swallowing “like there is a lump in my throat,” dent as possible with walking, dressing, showering, driving,
and she has noticed occasional slurred words. Amanda and being a student able to continue earning A’s in school.
continues to have difficulty walking and a loss of balance Amanda was not able to clearly state what she wanted to
since the accident. Prior to the hospital visit, Amanda was work on as goals. She kept her eyes closed and moaned
attending a charter high school, where she participated in because of reported pain in her left leg. The occupational
sports (basketball and soccer) and served as president of the therapist then briefly explained the rehabilitation process to
school’s Student Council. She was a straight A student and Amanda and her mother, describing her daily schedule with
she enjoyed socializing with friends. Amanda currently lives the physical therapist, speech-language pathologist, and
with her stepmother and father. occupational therapist. Amanda and her mother said they
Earlier this week, Amanda’s visited a large urban hospital understood the proposed therapy schedule.
for the first time to manage her problems. Upon receiving After the description of Amanda’s plan of care and
doctor’s orders for physical therapy, occupational therapy, schedule, her mother asked when she could go home. She
and speech therapy, each therapist read about Amanda’s expressed that she was concerned that Amanda would fall
medical history in the online medical chart. The therapists behind in her classes and that her grades would suffer. She
met interprofessionally to discuss a potential schedule for also worried that Amanda would lose her starting position
 Providing Interprofessional Medical Care for Children and Adolescents 163

on the soccer team. The occupational therapist responded 12. American Physical Therapy Association Section on Pediatrics. Fact
that the decision for discharge would be discussed by many sheet: Role and scope of pediatric physical therapy in fitness,
wellness, health promotion, and prevention. Academy of Pediatric
team members along with Amanda and her parents on the Physical Therapy Web site. https://pediatricapta.org/includes/fact-
basis that goals were met and Amanda’s medical status had sheets/pdfs/12%20Role%20and%20Scope%20in%20Fitness%20
improved. Health%20Promo.pdf. Published 2012. Accessed March 20, 2017.
13. American Speech-Language-Hearing Association. Position statement:
Prevention of communication disorders. American Speech-Language-
Hearing Association Web site. http://www.asha.org/policy/PS1988-
REFERENCES 00228/. Published 1988. Accessed March 20, 2017.
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Appendix A
Interprofessional Engagement
With Children
Testing Developmental Reflexes
Catherine Rush Thompson, PT, PhD, MS

Pediatric therapists share a common knowledge of neu- • Dress appropriately. (Consider various positions the
romotor development and appreciate reflexes commonly learner must assume during testing—allow for flexibil-
demonstrated by infants and children. Engaging learners ity and modesty.)
in a pediatric lab experience featuring developmental reflex • Wear professional attire including a nametag.
testing offers an opportunity for interprofessional observa-
• Remove jewelry, scarves, or perfume.
tion, discussion, and documentation of behaviors observed
during the testing session. • Plan the space and equipment needed for testing:
º Area should be clean (wiped with sterile wipes) and
free of clutter (use a freshly cleaned sheet for young
PREPARATION FOR TESTING infants).
º Equipment appropriate for the ages tested should be
available (eg, tilt board for tilting reactions).
Examiner(s): Prior to Testing
• Sterilize hands immediately before testing.
• Review all the developmental reflex tests. Consider
which reflexes will be performed on the infant or child.
• Make a copy of the developmental reflexes instructions FAMILY
and a form to document findings.
• Plan to observe the infant’s/child’s spontaneous behav- • Prepare the infant/child for testing:
iors before structured testing. º Ensure that the infant or child is well-rested and
• Decide who will conduct the various developmental comfortable. Typically, infants younger than 6
reflex tests. months are tested in diapers, whereas children older
• Inform the family about how to prepare for the testing than 1 year can wear comfortable clothing (prefer-
session. ably shorts and a short-sleeved T-shirt).

Thompson CR. Pediatric Therapy:

An Interprofessional Framework for Practice (pp 165-172).
- 165 - © 2018 SLACK Incorporated.
166 Appendix A

º Share information about the child (eg, likes, dis- • Evaluation:

likes, medical history, developmental history). º Normal: This reflex is present from 28 weeks’ gesta-
• Bring the child’s favorite blanket, toys, books, etc, for tion and integrated by 2 to 5 months.
comfort during testing, as needed. º Abnormal: Persistence beyond 3 months or lack
• Allow about 60 minutes for the entire test and discus- of response suggests neuromuscular problems.
sion with the interprofessional team after testing. Persistence may inhibit development of voluntary
• Ask the caretaker if she has any concerns and questions. sucking movements and oral sensory stimulation.
Sucking is often less intense and less regular during
first few days of life.
INSTRUCTIONS • Significance: Failure to develop interferes with nourish-
ment. Slower rate is seen in nutritive sucking, which
may be needed to coordinate with respiration and swal-
Many of these reflexes can be observed spontaneously
lowing in the feeding process.
during interactions with a young child; however, specific
stimuli commonly elicit predictable responses. If the typical
or normal responses are not observed during the typical time The Moro Reflex
frame, there could be factors limiting the child’s response. This reflex demonstrates the acquisition of adequate
The following procedures describe the stimulus and typical strength against gravity. The development of motor skills
response for developmental reflexes commonly observed.1-7 will suppress the expression of the Moro movement pattern.
• Procedure: Place child supine with head in the midline
Early Reflexes and arms on chest. Supporting the infant’s head and
These early reflexes are commonly observed in a newborn shoulders, allow the infant’s head to drop back suddenly
or young infant. 20 to 30 degrees with respect to trunk.
• Response: When the head is dropped, the infant typi-
Rooting Reflex cally extends and abducts the arms, then the extremities
are brought to midline. Lower extremity movement
(Performed on a hungry infant.)
is generally less obvious, but the same pattern of hip
• Procedure: The cheek or lips are brushed by a clean abduction and extension is normally followed by flex-
finger, pacifier, or facecloth. ion. This reflex is normally present at 8 weeks postna-
• Response: The lips and tongue will tend to follow in tally and may be present until 5 to 6 months of age.
that direction. Stimulation at corners of mouth elicits • Evaluation:
head turning toward stimulus.
º Normal: This reflex is present at 28 weeks’ gestation
• Evaluation and is integrated by 5 to 6 months.
º Normal: This reflex is present from 28 weeks’ gesta- º Abnormal: Persistence of this reflex suggests
tion up to 4 months, although the reflex may persist neuropathology.
up to 7 to 8 months depending upon the infant’s
Note: This reflex differs from startle reaction, which can
state of hunger and awake-sleep cycle.
be elicited by a loud noise or sudden light and consists of a
º Abnormal: Persisting beyond 8 months. Also note flexor movement only.
that excessive salivation, difficulty breathing, froth-
ing, or structural facial anomalies should be noted. Traction Response
Asymmetry may indicate insult to one side of the
brain or facial injury. Absent in babies depressed by • Procedure: Place child supine with head in the midline.
barbiturates. Grasp child’s forearms and pull to sitting position,
• Significance: This early reflex may contribute to typical stretching the shoulder adductors and arm flexors.
breast feeding and survival. • Response: Flexion of the shoulders, elbows, wrists, and
fingers. Increased muscle tension in the shoulder mus-
Sucking-Swallowing Reflex cles can be felt and observed even if head lag is present.
• Evaluation:
• Procedure: Place a finger or nipple in the infant’s
mouth. º Normal: This reflex is present at 28 weeks’ gestation
and is integrated by 5 to 6 months.
• Response: Rhythmic sucking movements.
 Interprofessional Engagement With Children: Testing Developmental Reflexes 167

º Abnormal: Lack of response or persistence suggests • Response: The child will follow the direction of the
neuromuscular pathology. head turn and roll toward that side without segmental
• Significance: Persistence may inhibit voluntary reach rotation (this is a “log-roll”).
and grasp. • Evaluation:
º Normal: This reflex is present at 34 weeks’ gestation
Palmar Grasp and is generally integrated by 4 to 5 months.
This reflex allows the infant to hold a rattle when placed º Abnormal: Persistence beyond 5 months. By 10
in her hand. months, an infant will typically roll independently
• Procedure: Place infant supine with head in the mid- using this reflex to assist in voluntary movement.
line and hands free. Place index finger in infant’s palm If it is much stronger in one direction than anoth-
from the ulnar side and gently press against the palmar er, this is a red flag for possible neuromuscular
impairment.
surface.
• Significance: This reflex allows child to roll supine to
• Response: Infant’s fingers will flex around the exam-
side and side to supine. Persistence may interfere with
iner’s finger.
the development of segmental rolling. The individual
• Evaluation: may have difficulties with other movement patterns
º Normal: This reflex is present at 28 weeks’ gestation that require rotational components or may fail to devel-
and is integrated by 5 to 6 months. Infants show op a variety of movement patterns and thus be limited
differential responses to hard and soft objects. to more stereotypical responses.
º Abnormal: Lack of response or persistence suggests
neuromuscular pathology. Neck-Righting Acting on the Body
• Significance: Persistence may inhibit development of
volitional grasp and release. • Procedure: Place child supine with head in midline and
extremities extended. Turn the child’s head to one side
Plantar Grasp and hold in this position with jaw over shoulder.
• Response: The child rolls segmentally in direction of
Suppression may occur through experience standing at a head turning.
support, cruising, and walking with and without assistance • Evaluation:
because these activities promote more functional postures
for the toes. º Normal: This reflex is seen at 4 to 6 months.
• Procedure: Place child in supine with head in midline º Abnormal: This reflex is typically integrated at
and legs relaxed. Exert pressure against the soles of 5 years (when child can get to standing without
infant’s foot, directly below toes. This reflex can also be rotation).
tested in standing. • Significance: This reflex allows the child to roll supine
• Response: Flexion of toes. to prone and prone to supine. This reflex is indicative
of the development of rotation around the body axis
• Evaluation:
(intra-axial rotation) and allows for rotational patterns
º Normal: This reflex is present at 28 weeks’ gestation necessary for rolling, attaining sitting, sitting, and
and is integrated by 9 months. Infants show differ- standing.
ential responses to hard and soft objects.
º Abnormal: Lack of response or persistence suggests Neonatal Body Righting
neuromuscular pathology.
• Significance: Persistence may inhibit development of • Procedure: Place child supine with head in midline.
volitional grasp and release. Flex one leg up toward the chest, and rotate the child’s
leg across the body, rolling the baby over.
Neonatal Neck-Righting Reaction • Response: The child’s thorax, chest, and head will fol-
low the direction of the pelvis, and the body will roll
This is an immature rolling pattern that lacks trunk rota- toward that side without segmental rotation (log roll).
tion and trunk segmentation.
• Evaluation:
• Procedure: Place child supine with head in midline and
extremities extended. Rotate head to one side actively º Normal: This reflex is typically seen at 34 weeks’
gestation and is integrated at 4 to 5 months.
or passively.
º Abnormal: This reflex is abnormal if it persists
beyond 5 months.
168 Appendix A

• Significance: This reflex allows child to roll supine • Response: Flexion, adduction, and then extension of
to side and side to supine. Asymmetry is not normal. the opposite lower extremity as if to push the examiner
Persistence interferes with the development of segmen- away. If the stimulated extremity is not fixed, the stimu-
tal rolling and acquisition of other developmental mile- lated leg will withdraw, and the opposite extremity will
stones that require rotation (see neck on body righting extend.
reflex). • Evaluation:
º Normal: The onset of this reflex is 28 weeks’ gesta-
Body-Righting Reaction Acting on the Body tion, with integration at 4 months.
• Procedure: Place child in supine with head in midline º Abnormal: The absence of this reflex in the young
and extremities extended. Flex one leg and rotate it infant or its persistence beyond 4 months is suspect.
across the pelvis to the opposite side. • Significance: Failure to obtain or late persistence may
• Response: Child will roll segmentally to prone (ie, first indicate general depression of the central nervous sys-
the trunk, then the pectoral girdle, and finally the tem or sensorimotor dysfunction. Persistence may pre-
head). vent typical reciprocal kicking and subsequent walking.
• Evaluation:
Proprioceptive Placing (Upper or Lower
º Normal: This reflex typically begins at 4 to 6
months and is integrated by 5 years (when child can Extremity) (Placing Reaction)
get to standing without rotation). • Procedure: Hold the child in a vertical position with
º Abnormal: Persistent and obligatory responses examiner’s hands under the arms and around the chest.
beyond 5 years. Move the child so that the dorsum of one hand or foot
• Significance: This reflex allows child to roll supine to presses lightly against the edge of the table.
prone and prone to supine. It is indicative of the devel- • Response: Infant will flex arm or leg respectively and
opment of rotation around the body axis (intra-axial place hand or foot on the table.
rotation) and allows for rotational patterns necessary for • Evaluation:
rolling, attaining sitting, sitting, and standing.
º Onset: The upper extremity placing reaction begins
at birth in the full-term infant.
Flexor Withdrawal
º Abnormal: Absence in early infancy or persistence
Do this test last because it can be noxious to the infant are suspect.
and can cause crying. • Significance: Correlates with spontaneous stepping
• Procedure: Place child supine with head in midline and (stepping reflex). May be obtained at any age if traction
legs relaxed and semiflexed. Apply a noxious stimulus, is exerted against the ankle or the wrist to the point of
such as pin prick, to sole of one foot. discomfort.
• Response: Brisk flexion of stimulated limb, withdraw-
ing from the stimulus; includes toe extension, dorsiflex- Visual Placing
ion, and hip/knee flexion.
• Procedure: Hold the child vertically under the arms and
• Evaluation: around the chest. Advance the child toward a support-
º Normal: This reflex typically begins at 28 weeks’ ing surface such as a table top.
gestation and is integrated by 1 to 2 months or when
• Response: Child will lift hand, extend it, and place it on
independent walking occurs.
the support with fingers extended and abducted or will
º Abnormal: Persistence of this reflex when walking immediately orient and place foot on top of supporting
occurs. surface.
• Significance: Persistence may indicate a delay in pos- • Evaluation:
tural maturation.
º Normal: This reflex begins at 3 to 5 months and
Note: This is a protective response that is never com- persists throughout life.
pletely inhibited although it loses dominance.
º Abnormal: Absent or delayed response.
Crossed Extension • Significance: This reflex requires visual input, relied on
for both postural control and guidance for locomotor
• Procedure: Place child supine with head in midline. progression. This reflex is associated with independent
Hold one lower extremity extended at the knee and walking and is important for weight bearing.
apply firm pressure or noxious stimulus to sole of
the foot.
 Interprofessional Engagement With Children: Testing Developmental Reflexes 169

Neonatal Positive Support • Significance: This reflex allows for creeping, attaining
sitting, and standing positions; allows for development
• Procedure: Hold infant in the vertical position with of shoulder stabilization and protective reactions; and
examiner’s hands under the arms and around the chest. prevents total effectiveness of protective reactions if
Allow feet to make firm contact with the tabletop or absent.
other flat surface.
• Response: Simultaneous contraction of flexors and Spontaneous Stepping
extensors in lower extremities so as to bear weight on (Stepping Reflex or Automatic Walking)
the lower extremities. The child supports only minimal
amount of body weight, characterized by partial flexion • Procedure: Support the infant in the vertical position
of the hips and knees. with examiner’s hands under the arms and around the
• Evaluation: chest with the child’s feet touching the table surface.
Incline the child forward and gently move the child
º Normal: This reflex begins at 35 weeks’ gestation
and is generally integrated by 1 to 2 months. forward to accompany any stepping.
• Response: Child will make alternating, rhythmical, and
º Abnormal: Absence or persistence of this reflex.
coordinated stepping movements.
• Significance: This is a prerequisite for spontaneous
stepping reflex. A typical response is needed for erect • Evaluation: The standing posture includes some flex-
standing and bipedal locomotion. ion of the hip and knee. Automatic stepping may also
be observed when the newborn is inclined forward
Positive Support Reaction (Lower Extremity) while being supported in this position. During the
first 4 months of life, the crouching position gradually
• Procedure: Support infant in the vertical position with diminishes; this is followed by increase in support, so
examiner’s hands under the arms and around the chest. that typical infants will usually support a substantial
Allow feet to make firm contact with the tabletop or proportion of their weight by 10 months. Scissoring or
other flat surface. standing on the toes are red flags for neuromuscular
• Response: Simultaneous contraction of the lower impairment. The feet may be examined for structural
extremity flexors and extensors for full weight bearing anomalies such as clubfoot.
on the lower extremities with hips and knees extended. º Normal: The onset is 37 weeks’ gestation and is
• Evaluation: integrated by 2 months.
º Normal: The onset is 6 to 9 months and persists º Abnormal: Absence or persistence.
throughout life. • Significance: Identical to kicking but different from
º Abnormal: Absence or delayed response. early true walking. May show nonstepping phase (aba-
• Significance: Neonatal positive support gradually merg- sia). Stepping reaction is integrated in parallel with neo-
es into active standing. The infant may show periods of natal positive supporting. Disappearance may be result
nonweight bearing (astasia). of dramatic increase in the mass of the legs, which can
no longer be raised against gravity.
Positive Support Reaction (Upper Extremity)
Attitudinal Postural Reflexes
• Procedure: Place child prone on floor or lower child to
surface to allow contact. Attitudinal reflexes are those that are associated with
• Response: Simultaneous contraction of flexors and emerging muscle tone.
extensors in upper extremity for full weight bearing
with shoulder flexion and elbow/wrist extension. An
Asymmetrical Tonic Neck Reflex
exaggerated or atypical response involves extensor • Procedure: Place child supine with head in midline (can
muscles dominating flexors (ie, shoulders are internally also test in sitting, quadruped, or standing, depending
rotated and adducted, elbows extended, wrists flexed, on child’s age). Turn child’s head to one side either pas-
and ulnarly deviated with hands fisted). sively or actively (have child follow an object from one
• Evaluation: side to the other).
º Normal: The onset is 3 to 6 months and persists • Response: The infant tends to assume a fencing posi-
throughout life. tion, with his face toward the extended arm, while the
º Abnormal: Absence or delayed response. other arm flexes at the elbow. The lower limbs respond
170 Appendix A

in a similar manner. The arm and leg on the face side • Evaluation:
extend; arm and leg on skull side flex OR increase in º Normal: The onset of this reflex can be as early as
extensor tone noted in face limbs and flexor tone in 38 weeks’ gestation and integration at 6 months.
skull limbs. º Abnormal: Absence in early infancy and/or persis-
• Evaluation: tence beyond 6 months is abnormal.
º Normal: Onset as early as 28 to 38 weeks (lower • Significance: Persistent obligatory response may pre-
extremities before upper extremities), commonly vent development of head lifting prone and/or supine,
seen at 2 to 4 months, and integrated by 6 months. development of prone on elbows, rising to sitting, roll-
Response is never totally obligatory in a typical ing, bringing hands to midline, and hand-to-mouth
infant; usually seen more as a posture (ie, fencer’s and hand-to-body exploration. Persistence may inter-
position). fere with all activities requiring a controlled balance
º Abnormal: Absence or persistence. Its presence after between flexors and extensors.
7 months suggests neurological impairment and the
need for a medical referral. Galant Reflex (Incurvatum of the Trunk)
• Significance: In full-term infants, upper extremi-
• Procedure: Place infant in prone in typical alignment.
ties participate more strongly than lower extremities.
Gently stimulate with fingernail along paravertebral
Persistence may interfere with development of typi-
line about 3 cm from midline from shoulder to buttocks.
cal rolling pattern, hand-to-mouth and hand-to-body
exploration, visually directed reaching, midline hand • Response: Lateral flexion of the trunk toward the side
activity, and symmetrical head lifting. Persistence may of the stimulus.
lead to scoliosis or hip subluxation. • Evaluation:
º Normal: Onset begins at 32 weeks’ gestation and
Symmetrical Tonic Neck Reflex integration by 2 months.
• Procedure: Place the child in quadruped position or º Abnormal: No response.
prone over the examiner’s knee. Passively flex and then • Significance: This is one of the most common reflexes
extend the child’s head. in typically developing newborns. Persistent response
may lead to scoliosis.
• Response: Flexion of the head produces flexion of the
upper extremities and extension of the lower extremi-
ties. Extension of the head produces extension of the
Landau Reflex
upper extremities and flexion of the lower extremities. • Procedure: Hold the infant in the air horizontally in
There is no reciprocal movement. the prone position. Be certain to offer full body support
• Evaluation: under the infant’s abdomen, allowing the upper trunk
º Normal: Onset at 4 to 6 months and integration at and legs to move freely against gravity.
8 to 12 months. • Response: Extension of the neck and trunk with pos-
º Abnormal: Absence of muscle tone. sible extension of the lower extremities against gravity.
• Significance: Integration of this reflex coincides with • Evaluation:
crawling in 4-point position. Persistence may inhibit º Normal: Onset at 3 months and integration between
development of reciprocal creeping; the child will bun- 12 to 24 months.
ny-hop instead. Persistence may inhibit development of º Abnormal: Lack of extension of the neck and trunk
typical sitting posture. or an exaggerated response with stiff extension of
the entire body.
Tonic Labyrinthine Reflex • Significance: This reflex indicates the infant’s ability
• Procedure: Place child prone or supine with head in to move the body against gravity. An inability to move
midline. Observe the child’s tone and posture or try to against gravity suggests low muscle tone and/or muscle
passively move the head and limbs. weakness. An exaggerated response suggests increased
muscle tone.
• Response: In prone, flexor tone dominates; child
will not lift head or support weight on arms. In
supine, extensor tone dominates; child will not flex in
pull to sit.
 Interprofessional Engagement With Children: Testing Developmental Reflexes 171

Righting Reactions • Evaluation:

º Normal: Onset at 6 to 9 months and persists
Optical Righting Reflex throughout life.
• Procedure: Examiner holds the child in space prone, º Abnormal: Absence or delayed response.
supine, or vertical and tilts the child in the vertical posi- • Significance: Coincides with ability to bring extended
tion; prone and supine position itself is stimulus. upper extremities forward for reaching out and bearing
• Response: Child rights head against gravity. weight.
• Evaluation:
Protective Extension Sideward
º Normal: Onset at 2 months and persists throughout (Upper Extremity) (Propping Reaction)
life.
º Abnormal: Lack of response. • Procedure: Place child in sitting with legs out in front.
• Significance: Allows child to lift head in prone or Push child on one shoulder with enough force to dis-
supine and secures position of head in space. place center of gravity and cause child to lose balance.
• Response: Child will abduct arm with extension of
Labyrinthine Head-Righting Reaction elbow, wrist, and fingers on the side opposite of force
and take weight on an open hand.
The stimulus is the same procedure as above; however,
• Evaluation:
you perform the test with the child’s eyes closed or covered.
A small bandana can be used to cover the eyes, but this is º Normal: Onset at 7 months and persists throughout
generally not tolerated for very long. life.
º Abnormal: Absence or delayed responses.
Landau Reflex (Sagittal Plane Righting Reflex) • Significance: Followed by positive supporting reaction
as soon as contact is made with the surface.
• Procedure: Holding the infant in vertical suspension
with the head, spine, and legs extended, the examiner
passively flexes the head forward.
Protective Extension Backward
• Response: Total body flexion with neck flexion is seen
(Upper Extremity) (Propping Reaction)
as early as 3 months. At 6 months, vertical suspension • Procedure: Place child in sitting with legs out in front.
elicits extension of the head, neck, and trunk. Push child backward with enough force to displace cen-
• Evaluation: ter of gravity and cause child to lose balance.
º Normal: Onset at 3 to 4 months, peaks at 5 to 6 • Response: Child will extend arms backward; full
months, and integration at 12 to 24 months. reaction involves backward extension of both arms.
º Abnormal: Absence associated with muscle weak- Frequently, an element of trunk rotation is seen and
ness or decreased extensor activity. only one arm extends.
• Significance: Not an isolated reaction; produced by • Evaluation:
labyrinthine righting, optical righting, body-righting º Normal: Onset is 9 to 10 months and persists
acting on the body, body-righting acting on the head, throughout life.
and neck righting. This reflex coincides with ability to º Abnormal: Absence or delayed responses.
assume pivot-prone or Superman posture. • Significance: Onset overlaps with other protective
reactions of the upper extremities.
Equilibrium Reactions
Protective Extension Downward (Lower
Protective Extension Forward Extremity) (Downward Parachute Reaction)
(Upper Extremity) (Parachute Reaction)
• Procedure: Hold child in vertical suspension and plunge
• Procedure: Support infant in inverted vertical position child downward toward surface.
in space with hands around the infant’s body. Carefully
• Response: Lower extremities externally rotate and
plunge child downward toward a table or other flat
abduct and feet dorsiflex in preparation for standing.
surface.
• Evaluation:
• Response: Upper extremities will extend and abduct;
fingers will extend and abduct as if to break the fall. º Normal: Onset at 4 months and persists
throughout life.
172 Appendix A

º Abnormal: Absence or delayed response. extend, arms extend and are retracted; to posterior
• Significance: Breaks a fall by extension of the knee tilt—spine flexes, displacing the body forward, legs
joint. extend, shoulders are flexed and elbows extended
• Evaluation:
Protective Staggering (Lower Extremity) º Normal: Typical onset for this reflex varies with
postures used in testing: prone, 5 months; supine,
• Procedure: With child standing on solid surface,
7 months; sitting, 7 to 8 months; quadruped, 9
push child in all directions (forward, backward, and
months; standing, 12 to 21 months. Integration—
sideways).
persists throughout life.
• Response: Child will make corrective movements with
• Significance: Adults rely most heavily on proprioceptive
limbs to restore center of gravity (eg, take steps forward
input, whereas children rely on visual input for postural
or back, cross one foot over the other). orientation. These reflexes are necessary for mainte-
• Evaluation: nance of balance in all postures.
º Normal: Onset at 15 to 18 months and persists
throughout life.
º Abnormal: Absence or delayed response. VIDEO RESOURCE
• Significance: Keeps the body oriented in space when
displaced by an external horizontal force. This reflex is PediNeuroLogic Exam. http://library.med.utah.edu/
needed for safe and independent ambulation. pedineurologicexam/html/newborn_n.html.Updated
August 2016. Accessed March 30, 2017.
Tilting Reactions The “Pediatric Neurologic Exam: A
Neurodevelopmental Approach” uses over 145 video
Tilting Reactions Dependent Upon demonstrations and narrative descriptions in an
Postures Tested online tutorial. It presents the neurological exami-
nation of the pediatric patient as couched within
• Procedure: For each test, the therapist positions the the context of neurodevelopmental milestones for
child in the appropriate position (eg, prone, supine, sit- newborns, 3-month-olds, 6-month-olds, 12-month-
ting, quadruped, kneeling, or standing on a tilt board). olds, 18-month-olds, and 2-and-a-half-year-olds.
• Responses (dependent upon position tested):
º Prone and supine: Child’s trunk is curved away
from the tilt, with the concavity of the spine
upward; slight abduction of the upper arm and leg
REFERENCES
may be seen. 1. Meyers RK. Reflex testing methods for evaluating CNS development.
º Sitting: To lateral tilt, body is laterally flexed away Pediatrics. 1964;33(1).
from the tilt, concavity of the spine upward, arm 2. New York State Department of Health. Motor disorders: Assessment
and leg on upper side abducted; to anterior tilt— and intervention for young children (age 03 years). https://www.
health.ny.gov/publications/4961.pdf. Published 2011. Accessed March
spine extends and limbs retract; to posterior tilt— 30, 2017.
spine flexes and limbs advance. 3. O’Dell N. The symmetric tonic neck reflex (STNR). http://www.ndc-
º Quadruped: To lateral tilt, body is laterally flexed brain.com/articles/SymmetricTonicNeckReflex.pdf. Accessed March
away from the tilt with concavity of the spine 10, 2017.
4. Schott JM, Rossor MN. The grasp and other primitive reflexes. J
upward; the head is slightly rotated so that the face Neurol Neurosurg Psychiatr. 2003;74(5):558-560.
turns toward the upper side; the arm and the leg on 5. Sohn M, Ahn L, Lee S. Assessment of primitive reflexes in high-risk
the upper side flex and the arm and leg on the lower newborns. J Clin Med Res. 2011;3(6):285-290.
side extend and abduct. 6. Stanford Children’s Health. Newborn reflexes. http://www.stan-
fordchildrens.org/en/topic/default?id=newborn-reflexes-90-P02630.
º Standing: To lateral tilt, body is laterally flexed away Accessed March 30, 2017.
from the tilt with the concavity of the spine upward; 7. Mitchell RG. The Landau reaction (reflex). Dev Med Child Neurol.
upper leg is flexed and upper arm abducted; lower 1962;4(1):65-70.
leg is extended and strongly braced; to anterior tilt
—spine extends, displacing the body backward, legs
Appendix B
Interprofessional Communication
Selecting Tests and Measures
Catherine Rush Thompson, PT, PhD, MS

Below are listed a sampling of tests used across a vari- Consider the various cases presented throughout this
ety of pediatric therapy settings. Although this list is not book and assessments (tests and measures) that could pro-
exhaustive, it offers a range of tests that may be considered vide the needed information to help solve the problems that
when collecting data for decision making. Learners should these children are encountering.
select the optimal measures for a given testing situation, 1. Select a case study from one of the sections in this book.
including the situation. The situation takes into account the 2. Look at the following categories of tests to select appro-
following: priate assessments to provided needed information to
• Demographics/characteristics of the child being assessed solve problems.
(eg, age, medical condition) 3. In the selection process, ask the following:
• Setting/specific location of testing (space for quiet test • Is the measure valid for the information being
administration) sought?
• Availability of assessment measures (available testing • Is the measure reliable and adequately sensitive for
equipment with criteria) testing and retesting a child?
• Examiner’s training, familiarity with the test, and abil- • Is the measure well designed for the population
ity to perform the test reliably being tested?
• Outcomes desired from the evaluation (eg, providing • Is the measure a survey or questionnaire that can be
information to qualify a child for services) given to the parent/caregiver/teacher/child?
• Interprofessional team members (expertise, skills, con- • Is the measure norm referenced or criterion refer-
cerns, and observations; keep in mind that certain tests enced? (Consider: Does the test need to be norm
are discipline-specific and/or require advanced training) referenced to determine eligibility for services?)

Thompson CR. Pediatric Therapy:

An Interprofessional Framework for Practice (pp 173-180).
- 173 - © 2018 SLACK Incorporated.
174 Appendix B

• Does the assessment need to be performed one- • Behavioral and Emotional Screening System Student
on-one with the child or does it lend itself to team Self-report Form (BESS)
administration (eg, observation of skills)? • Brief Infant-Toddler Social and Emotional Assessment
• Is the measure efficient for collecting needed data (BITSEA)
in a reasonable amount of time, given the child’s • Carey Temperament Scales
condition?
• Childhood Autism Rating Scale (CARS)
4. In your interprofessional team, discuss your rationale
• Devereux Early Childhood Assessment—Clinical Form
for using each selected test. If the tests listed below do
(DECA-C)
not provide needed information, search to see if another
test exists that meets desired criteria. • Devereux Early Childhood Assessment for Infants and
Toddlers (DECA I/T)
5. As a team, discuss how you would inform the family
about assessments selected (providing your rationale • Disruptive Behavior Rating Scale
regarding how the test addresses specific concerns while • Early Coping Inventory
avoiding jargon). • Evaluating Acquired Skills in Communication (EASIC)
• Functional Emotional Assessment Scale (FEAS)
• Gilliam Autism Rating Scale (GARS)
PEDIATRIC TESTS AND MEASURES • Infant-Toddler Social and Emotional Assessment
(ITSEA)
The following are examples of pediatric tests and mea-
• Modified Checklist for Autism in Toddlers, Revised
sures listed alphabetically under their respective categories.
with Follow-Up (M-CHAT-R/F)
Note that some categories overlap. Check current literature
for the most recent edition of each test, as well as populations • NICU Network Neurobehavioral Scale (NNNS)
that have been successfully evaluated with each measure.1-7 • Patient Health Questionnaire
• Screen for Child Anxiety Related Emotional Disorders
Activities (see also Development, Fine • Temperament & Behavior Scale (TABS)
Motor, Functional/Adaptive, Gross Motor, • Vineland Social-Emotional Early Childhood Scale
and Speech)
Cardiopulmonary
• Activities Scale for Kids (ASK)
• Blood pressure, heart rate, incentive spirometry, oxygen
Anthropometrics saturation, respiratory pattern and rate, skin color

• Observation of body dimensions, body composition, Cognitive/Adaptive Behavior

height/weight, leg length, body mass index, chest cir-
cumference, skinfold tests • Bay Area Functional Performance Evaluation (BAFPE)
• Bayley Scales of Infant and Toddler Development
Arousal (see also Behavior/Emotional Social) (Third Edition)
• Adelaide Coma Scale • California Verbal Learning Test Children’s Version
(CVLT-C)
• Coma Near Coma (CNC) Scale
• Cogstate Brief Battery (CBB)
• Coma Recovery Scale Revised (CRSR)
• Columbia Mental Maturity Scale (CMMS)
• Orientation Scale
• Conners’ Continuous Performance Test II (CPT II)
• Pediatric Glascow Coma Scale (pGCS)
• Dynamic Occupational Therapy Cognitive Assessment
for Children
Behavior/Emotional/Social (see also
• Functional Emotional Assessment Scales (FEAS)
Cognitive/Adaptive Behavior)8
• Kaufman Assessment Battery for Children (Second
• Achenbach Child Behavior Checklist Edition) (KABC-II)
• ADHD Rating Scale-IV • Lowenstein Occupational Therapy Cognitive
• Autism Behavior Checklist (ABC) Assessment
• Autism Diagnostic Observation Scale • McCarthy Scales of Children’s Abilities (MSCA)
 Interprofessional Communication: Selecting Tests and Measures 175

• NEPSY: A Developmental Neuropsychological • Lafayette Grooved Pegboard (GPT)

Assessment • Selective Control Assessment of the Lower Extremity
• Peabody Individual Achievement Test-revised (PIAT-R) • Test of Ideational Praxis
• Raven Progressive Matrices (RPM)
• Rey-Osterrieth Complex Figure Test (ROCF) Development
• Scales of Cognitive Ability for Traumatic Brain Injury • Ages & Stages Questionnaires (ASQ-3)
(for adolescents)
• Alberta Infant Motor Scale
• Stanford-Binet Intelligence Scales (5th Edition) (SB-5)
• Assessment, Evaluation, and Programming System for
• Trail Making Test (TMT) Infants and Toddlers (Second Edition) (AEPS)
• Vineland Adaptive Behavior Scales (VABS) • Batelle Developmental Inventory (Second Edition)
• Wechsler Individual Achievement Test (Second Edition) • Bayley Infant Neurodevelopmental Screener (BINS)
(WIAT-II)
• Bayley Scale of Infant Development (Third Edition)
• Wechsler Preschool and Primary Scale of Intelligence
• Brigance Inventory of Early Development III (IED III)
(Third Edition) (WPPSI-III)
• Carolina Curriculum for Infant and Toddlers with
• Wide Range Achievement Test 3 (WRAT-3)
Special Needs (CCITSN)
• Wide Range Assessment of Memory and Learning
• Carolina Curriculum for Preschoolers with Special
(WRAML)
Needs (CCPSN)
• Woodcock-Johnson III Tests of Achievement (WJ III
• Developmental Assessment of Young Children-2
Ach)
(DAYC-2)
• Woodcock-Johnson III Tests of Cognitive Abilities
• Developmental Profile 3
(WJ-III Cog)
• Early Learning Accomplishment Profile (ELAP)
Communication • FirstSTEp Screening Test for Evaluating Preschoolers
Motor Skills Acquisition in the First Year and Checklist
• Communication and Symbolic Behavior Scales: • Hawaii Early Learning Profile (HELP)
Developmental Profile
• Infant Toddler Developmental Assessment (IDA)
• MacArthur-Bates Communicative Development
• Infant Development Inventory (IDI)
Inventories
• INSITE (for visually/multi-sensory impaired)
• Peabody Picture Vocabulary Test (Third Edition)
(PPVT-III) • Merrill-Palmer–R Scales of Development (M-P-R)
• Preschool Language Scale-5 (PLS-5) • Movement Assessment Battery for Children (Movement
ABC-2)
• Receptive Expressive Emergent Language Scale III
(REEL III) • Mullen Scales of Early Learning (MSEL)
• Receptive One Word Picture Vocabulary Test • Peabody Developmental Motor Scales (Second Edition)
(PDMS-2)
• Reynell Developmental Language Scales—American
Version
Endurance/Energy Expenditure
• Rosetti Infant Toddler Language Scale
• Sequenced Inventory of Communication Development • Early Activity Scale for Endurance (EASE)
(SICD) • Energy Expenditure Index
• SKI-HI Learning Development Scales (Hearing • 6-Minute Walk Test
Impaired 0-3) • 30-Second Walk Test
• Test of Early Communication and Emerging Language
Environment
Coordination
• Pediatric Environmental Home Assessment9
• Clinical Observation of Motor and Postural Skills
(COMPS) Fine Motor
• Florida Apraxia Screening Test
• Assisting Hand Assessment
• Gross Motor Performance Measure (GMPM)
176 Appendix B

• Bruininks-Oseretsky Test of Motor Proficiency • Test of Infant Motor Performance (TIMP)

(BOTP-2) • Timed Obstacle Ambulation Test
• Erhardt Developmental Prehension Assessment • Timed Up and Down Stairs Test
• Evaluation Tool of Children’s Handwriting • Timed “Up & Go” (TUG)
• Halstead–Reitan Grip Strength Test • Toddler and Infant Motor Evaluation (TIME)
• Harris Infant Motor Test (HINT)
• Jebsen Taylor Test of Hand Function Health Status
• Melbourne Unilateral Upper Limb Function (MUUL) • Child Health and Illness Profile Adolescent Edition
• Nine-Hole Peg Test (CHIP-E)
• Peabody Developmental Motor Scales (Second Edition) • Child Health Assessment Questionnaire (CHAQ)
(PDMS-2) • Child Health Questionnaire (CHQ)
• Shriner’s Upper Extremity Assessment • Health Utilities Index-Mark

Fitness Hearing
• FitnessGram • Conditioning Play Audiometry (CPA)
• Presidential Physical Fitness Test • Early Listening Function (ELF)
• Sit and Reach Test • Evoked Otoacoustic Emissions (OAE)
• Pure tone hearing test (air)
Functional/Adaptive Skills
• Select Picture audiometry
• Canadian Occupational Performance Measure (COPM) • Speech Awareness Thresholds (SAT)
• Do-Eat Assessment Evaluation ToolKit • Speech Discrimination Test
• Functional Independence Measure (WeeFIM) • Tympanometry Visual Reinforcement Audiometry
• Goal-Oriented Assessment of Life Skills (GOAL) (VRA)
• Oral-Motor/Feeding Scale
• Pediatric Evaluation of Disability Inventory (PEDI)/ Integumentary
PEDI-CAT • Lund Browder Chart
• POSNA Pediatric Musculoskeletal Functional Health • Observation of skin color/skin turgor
Questionnaire
• Pediatric Burn Assessment
• Vineland Adaptive Behavior Scales
• Starkid Skin Scale
Gross Motor Language Comprehension
• Alberta Infant Motor Scale (AIMS)
• Clinical Evaluation of Language Fundamentals-4
• Bruininks-Oseretsky Test of Motor Proficiency (CELF-4)
(BOTP-2)
• Comprehensive Assessment of Spoken Language
• Dynamic Gait Index (DGI) (CASL)
• Functional Mobility Assessment • Fullerton Language Test for Adolescents (Second
• Gross Motor Function Measure (GMFM) Edition)
• Gross Motor Performance Measure • Functional Communication Profile
• High Level Mobility Assessment Tool (HIMAT) • Oral-Written Language Scale (OWLS)
• Motor Function Measure • Oral-Written Language Scale-2 (OWLS-2)
• Observational Gait Scale (OGS) • Test of Adolescent and Adult Language (Third Edition)
• Peabody Developmental Motor Scales (Second Edition) (TOAL-3)
(PDMS-2) • Test of Language Development-Intermediate (Third
• Standardized Walking Obstacle Course Edition) (TOLD-I:3)
• Test of Gross Motor Development (Second Edition) • Test of Language Development-Primary (Third
(TGMD-2) Edition) (TOLD-P:3)
 Interprofessional Communication: Selecting Tests and Measures 177

Language Development—Preschool • Receptive One-Word Picture Vocabulary Test

(ROWPVT)
• Clinical Evaluation of Language Fundamentals-
Preschool (CELF-pre) Mental Health/Coping
• Preschool Language Assessment Instrument (PLAI)
• Preschool Language Scale-5 (PLS-5) • Abuse Assessment Screening
• Receptive-Expressive Emergent Language Test (Third • Bright Futures Surveillance Questions
Edition) (REEL-3) • Depression Scale for Children (CES-DC)
• Rossetti Infant-Toddler Language Scale • Devereux Early Childhood Assessment (DECA)
• Structured Photographic Expressive Language Test- • Early Coping Inventory
Preschool (SPELT-P) • Multidimensional Scale of Social Support Parent Stress
• Test of Early Language Development (Second Edition) Inventory
(TELD-2) • Revised Children’s Anxiety and Depression Scale
• SAD PERSONS Scale (for suicide risk)
Language Expression • Strengths and Difficulties Questionnaire
• Expressive Language Test (ELT)
• HELP Test—Elementary
Motor Planning/Motor Processing Skills
• Patterned Elicitation Syntax Test (PEST) • Assessment of Motor and Processing Skills (AMPS)
• Structured Photographic Expressive Language Test • Kaufman Speech Praxis Test for Children (KSPT)
(Third Edition) (SPELT-3) • Motor Planning Maze Assessment
• Test for Examining Expressive Morphology (TEEM) • School Assessment of Motor and Processing Skills
• Test of Narrative Language (TNL) (AMPS)
• WORD Test—Adolescent
• WORD Test—Elementary Neurological
• Quick Neurological Screening Test-II (QNST-II)
Language—Receptive
• Language Processing Test—Revised (LPT-R) Oral Speech
• Listening Test • Stuttering Prediction Instrument
• Rhode Island Test of Language Structure (RITLS) • Stuttering Severity Instrument (Third Edition) (SSI-3)
• Test of Auditory Comprehension of Language (Third • Stuttering Severity Scale
Edition) (TACL-3) • Test of Childhood Stuttering (TOCS)
• Token Test for Children
Pain
Language—Vocabulary
• Behavioral Pain Scale
• Assessing Semantic Skills through Everyday Themes • Children’s Hospital of Eastern Ontario Pain Scale
(ASSET) (CHEOPS)
• Carolina Picture Vocabulary Test for Deaf and Hearing • CRIES Scale (Cries, Require Oxygen, Increased Vital
Impaired (CPVT) Signs, Expression, Sleep)
• Comprehensive Receptive and Expressive Vocabulary • FACES Pain Scale
Test (Second Edition) (CREVT-2) • FLACC (Faces, Legs, Activity, Crying, Consolability
• Expressive One-Word Picture Vocabulary Test Behavioral Pain Scale)
(EOWPVT) • Individualized Numeric Pain Scale (INRS)
• Expressive One-Word Picture Vocabulary Test-Upper • Infant Pain Scale (IPS)
Extension (EOWPVT-UE)
• Neonatal Pain, Agitation and Sedation Scale (NPASS)
• Expressive Vocabulary Test (EVT)
• Numeric Scale
• Peabody Picture Vocabulary Test-III (PPVT-III)
• Oucher Scale
• Visual Analog Scale (VAS)
178 Appendix B

Participation • Pediatric Outcomes Data Collection Instrument

(PODCI)
• Adaptive Behavior and Participation Scales
• Pediatric Quality of Life Inventory (PEDS QL)
• Adaptive Behavior Scales (VINELAND-II OR VABS)
• Preferences for Activities of Children (PAC)
• Assessment of Functional Living Skills (AFLS)
• Quality of Well Being Scale (QWB)
• Developmental Assessment for Individuals with Severe
• School Function Assessment (SFA)
Disabilities–Third Edition (DASH-3)
• Short Child Occupational Profile
• Functional Assessment and Curriculum for Teaching
• Spinal Cord Injury—Quality of Life Anxiety
Everyday Routines (FACTER)
• Spinal Cord Injury—Quality of Life Psychological
• Functional Independence Skills Handbook (FISH)
Trauma
• Scales of Independent Behavior-Revised (SIB-R)
• Vineland Adaptive Quality of Life: Child Health Index
• School Function Assessment (SFA)
of Life with Disabilities
Personal Factors Range of Motion
• HABITS questionnaire10,11
• Ely’s Test
• Pediatric Motivation Scale
• Hamstring Length Test
• Modified Ober Test
Play
• Popliteal Angle
• Knox Preschool Play Scale • Prone Hip Extension Test
• Preschool Play Scale • Spinal Alignment and Range of Motion Measure
• Revised Children’s Assessment of Participation and (SAROMM)
Enjoyment and Preferences for Activities of Children • Straight Leg Test
(CAPE/PAC)
• Thomas Test
• Test of Playfulness (ToP)
• Transdisciplinary Play-Based Assessment, Second Reflexes (Developmental Reflexes: see
Edition (TPBA2)
Appendix A)
Posture/Balance • Movement Assessment of Infants (MAI)
• Peabody Developmental Motor Scales (Second Edition)
• Early Clinical Assessment of Balance (ECAB)
(PDMS-2)
• Movement Assessment of Infants (MAI)
• Pediatric Balance Scale (PBS) Sensory Integrity
• Pediatric Clinical Test of Sensory Interaction for
Balance (P-CTSIB) • Cranial nerve testing, sensory testing of superficial and
combined sensations
• Pediatric Reach Test (Pediatric Functional Reach Test)
• Timed Up and Down Stairs Test
Sensory Integration and Praxis
Quality of Life/Participation • Sensory Integration and Praxis Test (SIPT)
• Assessment of Life Habits (LIFE-H)
Sensory Processing
• Canadian Occupational Performance Measure (COPM)
• Child Occupational Self-Assessment • Adolescent/Adult Sensory Profile
• Children’s Assessment of Participation and Enjoyment • Child Sensory Profile 2
(CAPE) • Sensory Integration and Praxis Test
• Kidscreen • Sensory Processing Measure (SPM)
• Miller Function and Participation Scales • Sensory Profile
• Participation and Environment Measure-Children and • Test of Sensory Functioning in Infants
Youth (PEM-CY)
 Interprofessional Communication: Selecting Tests and Measures 179

Spasticity • Ryder’s Test

• Talar Tilt
• Modified Ashworth Scale (MAS)
• Transmaleolar Axis
• Modified Tardieu Test
Swallowing
Speech—Articulation
• Endoscopic assessment
• Arizona-3
• Modified barium swallow
• Clinical Assessment of Articulation and Phonology
(CAAP) • Observation (posture, behavior, oral motor control)
• Contextual Probes of Articulation Competence (CPAC)
Vision/Visual Motor/Perception
• Fisher-Logemann Test of Articulation Competence
• Goldman Fristoe Test of Articulation-2 (GFTA-2) • Beery-Buktenica Developmental Test of Visual-Motor
• Hodson Assessment of Phonological Patterns-3 Integration (6th Edition) (Beery Vmi)
(HAPP-3) • Bender Visual Motor Gestalt Test (Bender)
• Photo Articulation Test (Third Edition) (PAT-3) • Developmental Test of Visual Motor Integration
• Weiss Comprehensive Articulation Test (WCAT) • Developmental Test of Visual Perception (DTVP-2)
• Motor Free Visual Perception Test (4th Edition)
Speech—Phonology (MVPT-4)
• Oregon Project Global Assessment Tool
• Assessment Link between Phonology and Articulation
(ALPHA) • Test of Visual Motor Skills-3 (TVMS-3)
• Assessment of Phonological Processes-Revised (APP-R)
• Comprehensive Test of Phonological Processing
(CTOPP)
REFERENCES
• Hodson Assessment of Phonological Patterns-Third The list of measures is adapted from a combination of
Edition (HAPP-3) sources listed below:
• Khan-Lewis Phonological Analysis-2 (KLPA-2) 1. American Academy of Pediatrics. Mental health screening and
assessment tools for primary care. https://www.aap.org/en-us/advo-
• Phonological Awareness Test
cacy-and-policy/aap-health-initiatives/Mental-Health/Documents/
MH_ScreeningChart.pdf. Accessed April 2, 2017.
Strength/Muscle Power 2. American Physical Therapy Association, Section on Pediatrics. List of
pediatric assessment tools categorized by ICF model. https://pediatricap-
• Dynamometry ta.org/includes/fact-sheets/pdfs/13%20Assessment&screening%20
• Manual muscle testing tools.pdf. Published 2012. Accessed March 30, 2017.
3. Home Speech Home. 90+ speech therapy test descriptions and report
• Selective Control Assessment of the Lower Extremity outlines. http://www.home-speech-home.com/speech-therapy-test-
(SCALE) descriptions.html. Accessed April 2, 2017.
4. American Speech-Language-Hearing Association. Feeding and swal-
lowing disorders (dysphagia) in children. http://www.asha.org/public/
Structural Integrity speech/swallowing/Feeding-and-Swallowing-Disorders-in-Children/.
Accessed April 2, 2017.
• Adam Forward Bend Test 5. East Michigan University Library. Occupational therapy – Tests,
• Anterior/Posterior Drawer Test assessments, tools and measures. http://guides.emich.edu/c.
• Apley’s Test php?g=259436&p=2081301. Accessed April 1, 2017.
6. Illinois Department of Human Services. arly Intervention Approved
• Arch Index Evaluation and Assessment Instruments. http://www.dhs.state.il.us/
• Beighton Scale of Hypermobility page.aspx?item=86067. Published August 1, 2016. Accessed December
11, 2017.
• Craig’s Test 7. Rehabilitation Institute of Chicago, Center for Rehabilitation
• Galleazi Sign Outcomes Research, Northwestern University Feinberg School of
Medicine Department of Medical Social Sciences Informatics Group.
• Heel Bisector Angle Rehabilitation measures database. http://www.rehabmeasures.org/
• Lachman’s Test default.aspx. Accessed March 31, 2017.
• McMurray’s Test 8. Campbell JM, Brown RT, Cavanagh SE, Vess SF, Segall MJ.
Evidence-based assessment of cognitive functioning in pediatric psy-
• Navicular Drop Test chology. J Pediatr Psychol. 2008;33(9):999-1014.
180 Appendix B

9. National Center for Healthy Housing. Pediatric environmental 11. Wright ND, Groisman-Perelstein AE, Wylie-Rosett J, Vernon N,
home assessment. http://healthyhousingsolutions.com/wp-content/ Diamantis PM, Isasi CR. A lifestyle assessment and intervention tool
uploads/2014/12/HHAPP_Ex_2 _PEHA _ Survey-Nov2013.pdf. for pediatric weight management: the HABITS questionnaire. J Hum
Accessed April 4, 2017. Nutr Diet. 2011;24(1):96-100.
10. Tatla SK, Jarus T, Virji-Babul N, Holsti L. The development of
the Pediatric Motivation Scale for rehabilitation. Can J Occup Ther.
2015;82(2):93-105.
Appendix C
Interprofessional Collaboration
Wheelchair and Seating Evaluation
Catherine Rush Thompson, PT, PhD, MS

The interprofessional team should work closely together speech therapist, and the rehabilitation technology supplier/
with children and their families to buy needed assistive durable medical equipment vendor.
technology, including assistive, adaptive, and rehabilitative Examples of questions to ask the family and others
devices for mobility, communication, and engagement in include the following:
daily activities. A wheelchair can be a costly piece of custom- 1. What are the purposes of the wheelchair (eg, mobil-
ized equipment, so detailed features and accessories for the ity, therapeutic positioning, sports, recreation, travel,
wheelchair should be discussed by all team members before classroom activities)?
recommending a specific model with expensive adaptations. 2. What features are most important to the child and
The wheelchair evaluation begins with an interview of the family?
the child and family, focusing on the family’s needs, their 3. What activities will the wheelchair be used for less
daily routines, and general lifestyle. For children who spend frequently?
time outside of the home (eg, preschool, school, sports activ-
ities, community activities), others’ inputs are critical for 4. What daily activities must be accommodated (eg,
determining whether one chair is suitable to meet the child’s use of computer or assistive technology, carrying
needs and what special features are needed to meet multiple objects, moving through narrow spaces, use on rug-
demands. Those with the greatest expertise, generally the ged terrain)?
pediatric therapists, should offer recommendations for opti- 5. Where will the wheelchair be used the most (eg,
mal positioning and functioning in the wheelchair. Those home, school, transportation, community)?
typically involved in wheelchair and seating teams include 6. How will the wheelchair be moved from place to
the physical therapist, the child (if old enough to contrib- place (eg, self-propelled, motorized, collapsible)? The
ute ideas), family members involved in decision making, a team should consider distances inside the home, at the
family advocate (if needed), the occupational therapist, the school, and in the community to determine whether

Thompson CR. Pediatric Therapy:

An Interprofessional Framework for Practice (pp 181-182).
- 181 - © 2018 SLACK Incorporated.
182 Appendix C

the child has the ability to maneuver in a wide range necessary. It is important to state the long-term benefits of
of environments. recommended features, which can include the following:
7. How much of the day will the child be spending in • Bone growth and postural alignment
the wheelchair? • Strengthening of antigravity muscles
8. Does the wheelchair have features that will allow • Development of eye-hand coordination
functional independence (eg, transfers, fine motor • Opportunity for cognitive growth
function, self-feeding)?
• Respiratory activity
9. Does the wheelchair have features that enable safe
• Development of postural control
mobility and transportation (eg, anti-tip devices,
locks)? • Social acceptance
10. What environmental features should be considered • Improved self-esteem
(eg, various surfaces, slopes, doorways)? • Participation in daily activities
11. What is the cost, and who pays for the wheelchair? • Mobility (potentially independent)
12. How soon can the wheelchair arrive (to address pos- As a team, make recommendations for the following case
sible growth between when the wheelchair is ordered studies:
and when it arrives)? 1. Bobby is a 22-month-old with transverse myelitis at
13. When is the child eligible for another new wheelchair the C6 level (comparable to a complete C6 lesion). He
(to take into account the need for potential growth needs a mobility device in his early childhood special
over several years)? education setting.
The team should consider the range of options available, 2. Joanie is a 6-year-old with cerebral palsy (spastic
including the weight of the wheelchair, its portability, its quadraparesis). She has poor head control, moder-
versatility, and its ability to tilt in space, among others. A ate spasticity of her extremities, and low tone in her
comprehensive summary with findings and recommenda- trunk. She is nonambulatory and nonverbal, and her
tions can outline special features that the team justifies for gross and fine motor skills are significantly impaired.
a medical prescription. A letter of justification is typically She can move a lever forward 2 inches with her right
written by a person familiar with the child/family and the hand, she can log roll from prone to supine, and she
product recommended, then signed by a physician. Usually has difficulties with feeding and swallowing. Her
it is a therapist, but, in some cases, experienced rehabilita- home is full of equipment: therapy balls, mats, a
tion technology suppliers write them. This letter takes the stander, and a few different adapted chairs. At home,
recommendations that come out of the evaluation team and Joanie spends most of her day on the floor. The
correlates them to the features of a recommended wheel- elementary school and family are seeking a wheelchair
chair or seating system. This letter of justification helps that will enable Joanie to participate in the activities
the third-party payer understand why certain features or throughout the school day while ensuring safety when
characteristics of the recommended equipment are medically Joanie is bused to and from school.
Appendix D
Pediatric Professional Role Play
A Case for Assistive Technology
Pamela Hart, PhD, CCC-SLP

The goal of this case is to encourage critical thinking 6. Explain the importance of various types of human
regarding the design and use of augmentative and alternative factors and how these impact the successful imple-
communication (AAC) strategies for individuals with cere- mentation of AAC.
bral palsy or other severe speech and physical impairments. 7. Apply Baker’s ergonomic equation to the study of
human factors and AAC.

BASIC LEARNING OBJECTIVES

CASE DESCRIPTION
The learner will:
1. Define assistive technology and AAC. Bailey is a 7-year-old girl with cerebral palsy who is
2. Describe the roles of various professionals who work unable to walk or speak. She has limited functional use of
with individuals who use AAC strategies. her hands and is dependent on her caregivers for most activi-
3. Describe the communication needs of individuals ties of daily living, such as bathing, eating, and mobility.
with cerebral palsy. Due to her severe physical impairments, Bailey is unable
4. Describe why AAC is often needed for individuals to communicate verbally. Instead, she communicates by
with cerebral palsy and how this affects the develop- pointing to pictures that represent various basic needs, such
ment of speech skills. as “hungry,” “tired,” and “pain.” The picture cards are kept
on her wheelchair tray and are also laminated on a commu-
5. Define human factors and how these apply to every-
nication board for times when she is not in her wheelchair.
day life.
Bailey attends school in a program for children with ortho-
pedic impairments. Her parents have also sought outside ser-
vices for Bailey at a pediatric rehabilitation, where she works

Thompson CR. Pediatric Therapy:

An Interprofessional Framework for Practice (pp 183-187).
- 183 - © 2018 SLACK Incorporated.
184 Appendix D

with a variety of professionals, including a speech-language library. We will have the devices for several weeks so we
pathologist, occupational therapist, physical therapist, and can try them out in different settings without requiring too
consultant special education teacher. Additionally, Bailey much of her all at one time.”
receives care from her pediatrician, neurologist, and ortho- Occupational therapist: “Visually, she should do okay
pedic specialist on a regular basis. Bailey’s health concerns differentiating between the pictures on the communication
include (a) mild strabismus, (b) limited fine and gross motor device screen. I think the main challenge will be getting
skills, (c) inability to communicate verbally, and (d) a mild Bailey excited to use the device and finding access methods
intellectual impairment. that will allow her to be as independent as possible.”
For the most part, Bailey understands everything that
is said to her, but she is extremely limited in her ability to
respond. She has a form of spastic cerebral palsy that results
in hypertonic muscles, which makes volitional movement of
BASIC KNOWLEDGE QUESTIONS
her extremities difficult to control. Recently, Bailey’s speech- 1. What is cerebral palsy? When and how does it occur?
language pathologist suggested the team begin to explore
2. What are the characteristics of spastic cerebral palsy?
AAC devices to assist Bailey with her ability to make a wider
How do these characteristics differ from ataxic and
range of needs known and understood. The team has decid-
dyskinetic cerebral palsy?
ed to meet as a group and discuss Bailey’s strengths, needs,
and potential to benefit from AAC. Some of the dialog from 3. Describe the professional roles of speech-language
this initial meeting is provided here: pathologists, occupational therapists, and physi-
Speech-language pathologist: “Thank you for taking the cal therapists in working with children who have
time to meet today. I would like to discuss Bailey’s com- severe speech and physical impairments such as
munication challenges. She is working hard in therapy to cerebral palsy.
vocalize sounds, but it is difficult, and she hasn’t progressed 4. Why do you think is it important to use an interdisci-
as much as I would have liked. She is doing well communi- plinary team when working to determine appropriate
cating basic wants and needs with her picture cards on her assistive technologies for clients with severe physical
wheelchair tray. I think it is time to consider a high-tech and communication impairments?
AAC device that will allow her to have access to unlimited
vocabulary to meet both her social and academic needs.”
Bailey’s mom: “Will using an AAC device keep Bailey ASSISTIVE TECHNOLOGY AND
from learning how to speak? I really want her to continue
working on developing her speech skills.” AUGMENTATIVE AND ALTERNATIVE
Speech-language pathologist: “No, if anything, AAC helps
to promote verbal speech development. Bailey will be able
COMMUNICATION
to relax and communicate for longer periods of time, which
Assistive technology includes any devices or equipment
will also help her general level of language development too.”
used to give individuals with special needs the ability to
Occupational therapist: “I think it is a good idea to try participate as fully as possible in their family, community,
AAC. My concern is whether she will be able to access the educational, and vocational needs. It includes items such
device with her hands. She is able to isolate a finger to point, as assistive listening devices, prosthetics, adapted com-
but the devices require varying levels of pressure to activate puter access, mobility aids, environmental control aids,
the messages, and I’m not sure if she will be successful with adapted play tools, and AAC devices. Most humans are
that.” able to meet their communication needs by verbal speech.
Speech-language pathologist: “Yes, I think potentially However, for some individuals, physical and/or cognitive
there will be several areas to problem solve as we try this. impairments limit the effectiveness of their verbal speech
The devices can be adjusted to allow for differing levels of communication. AAC is one type of assistive technology
sensitivity, and we can also put a key guard over the screen designed to help individuals with severe speech impairments
to help with her accuracy.” to communicate.
Physical therapist: “I think we will need to be cautious Populations who benefit from AAC include children
that we do not wear her out with requiring too much motor and adults with developmental disabilities such as autism
control to access the device. I think we should start slow and and Down syndrome, physical disabilities affecting speech
maybe just use the device during certain activities to let her production such as cerebral palsy, and acquired disabilities
become familiar and see how she responds.” such as traumatic brain injury and stroke. AAC strategies
Speech-language pathologist: “I will be able to obtain range from high-tech computerized systems for voice out-
some devices on loan through the assistive technology loan put to low-tech picture-based systems and communication
 Pediatric Professional Role Play: A Case for Assistive Technology 185

books. The goal is to help the individual to become a more lives every-day as we attempt to interact with devices and
competent communicator.1 The myth that using AAC will technologies that sometimes do not lend themelves to error
hinder or limit verbal speech production has long been dis- free or obvious use.
proven. It has been found that in individuals with develop- Human factors is a critical component of any AAC
mental disabilities, AAC increases verbal speech production device. Individuals who require AAC often experience not
modestly.2,3 only communication problems but also fine motor, gross
motor, vision, cognitive, and hearing difficulties. As such,
considerations of the global needs of the individual must
APPLICATION QUESTIONS: be considered when choosing an AAC device. Baker’s
ergonomic equation (1986) provides a way to understand
AAC AND ASSISTIVE TECHNOLOGY how human factors impact the success or failure of assistive
technologies and AAC. In this equation, the motivation of
1. Why is it important to involve an interdisciplinary the individual to use the assistive technology must exceed
team in the assessment of individuals who require the sum of the physical effort, cognitive effort, linguistic
assistive technology? effort, and time load to operate the technology. Physical
2. Search for vendors of assistive technology equipment effort includes the individual’s ability to produce the motor
on the internet. Review the equipment and describe movements that result in accurate activation and use of the
some of the assistive technologies for mobility and assistive technology. Cognitive effort consists of the level of
communication that might benefit individuals such cognitive resources required to understand and operate the
as Bailey. technology. Specifically related to AAC, cognitive effort
3. How might the assistive technology needs of individu- includes the individual’s ability to remember where the mes-
als with congenital disabilities differ from those with sages are stored within the device, the ability to problem
acquired disabilities? solve when communication breakdowns occur, and the abil-
ity to go through the multiple steps of the communication
4. Critique the following systematic review and discuss
process using the device. Linguistic effort is the individual’s
the ideas presented by the authors that AAC promotes
ability to understand the mode of language representation
rather than hinders verbal speech development.2
within the AAC device. Options for representing linguistic
information include written words, line drawings, colored
pictures, and/or photos of real objects. The level of abstract-
HUMAN FACTORS ness the individual is able to understand related to their
ability to use symbols to represent language impacts their
Human factors is a field of study that analyzes the ways ability to understand what the pictures within the device
that human beings interact with technology. Formally represent. Time load is how long it takes the individual to
defined by the International Ergonomics Association, work through the sometimes multiple steps to create and
human factors is “the scientific discipline concerned with activate a message. Motivation is sometimes misunderstood
the understanding of the interactions among humans in AAC. Most individuals are highly motivated to com-
and other elements of a system, and the profession that municate, but their ability to realize this goal will be largely
applies theoretical principles, data and methods to design impacted by their team’s ability to anticipate and balance
in order to optimize human well-being and overall system the human factors of physical, cognitive, linguistic, and time
performance.”4 load to make this possible. If a person with a communica-
This type of analysis helps technology companies develop tion impairment is told that she will be given a check for
equipment that is safe and easy to operate and has built-in $1000.00 if she can say the word “eat,” it could be assumed
error prevention strategies. In daily life, human factors has the individual is highly motivated. If, however, there is no
many implications. For example, in many cars, the fuel efficient or effective means the individual is able to use to
gauge is on the same side of the dashboard as the fuel tank convey this message, all the motivation in the world will not
is positioned on the outside of the car. This way, drivers enable her the ability to communicate the word “eat.”
know which side of the car needs to be next to the gas pump
when pulling into a gas station. Don Norman’s book, The
Design of Everyday Things, explores and critiques daily life
experiences with design. For example, Norman describes the
APPLICATION QUESTIONS:
experiences of a friend who became trapped between 2 sets HUMAN FACTORS
of doors because the design of the doors made it difficult
to determine whether they should be pushed or pulled, and 1. Describe a time when your motivation to learn a new
they lacked handles or other cues. Human factors affect our piece of technology was not enough to overcome the
186 Appendix D

cognitive, time, physical, and/or linguistic load factors be easier for Bailey to have more choices on each page. With
to learn the new technology. this change, however, Bailey will no longer be able to use
2. Describe a time when you were highly motivated to direct selection to activate the device. Instead, she will need
learn to use a piece of technology but the design of to use a switch and an automatic scanning option within the
the technology made it very difficult to understand. device so that when she pushes the switch, the device begins
What do you think could have been improved within to highlight the messages on the screen one at a time, and
the design of the technology to correct this? when the correct message is highlighted, Bailey pushes the
3. What are ways to decrease the cognitive load for an switch again to choose that message.
individual learning to use an AAC device? 1. Explain how this change will affect the various
4. What are ways to decrease the physical load for an human factors across cognitive, linguistic, physical,
individual with cerebral palsy who is learning to use a and time considerations.
high-tech AAC device? 2. Review websites for manufacturers of various switched
5. What would be some ways to decrease the linguistic input products such as AbleNet and Enabling Devices.
load factors for an individual who was struggling to Which type of switch do you think might work best
learn how to use his AAC device because the symbols for Bailey to access with a light touch of her finger?
were too abstract? Bailey’s speech-language pathologist knows that Bailey
6. How does the concept of motivation apply to indi- needs access to a lot of vocabulary to be able to demonstrate
viduals learning to communicate via AAC? her academic and personal knowledge. She also wants Bailey
to communicate to meet many functions and intentions of
communication. She advocates for the vocabulary of the
device to include messages that help Bailey meet several
TEAM DECISION language functions, including requesting, asking questions,
establishing social closeness, and using her imagination
After the initial meeting, Bailey’s team decided to con- when she is playing.
duct an 8-week trial with a high-tech dedicated AAC device. 1. Why is it not enough for Bailey to have a means to
During the evaluation, Bailey was able to use direct selection communicate her basic wants and needs?
(pointing and pushing with her finger) to make selections on 2. Think of all the different ways you use communica-
the AAC device as long as there are no more than 6 pictures/ tion in a typical day. Make a list of all the categories
messages on each page. This required Bailey to access mul- of vocabulary words you need. Now, consider Bailey’s
tiple levels of the device to find the relevant vocabulary for needs in home, community, and school environments
meal times. For example, Bailey chose the icon for “food” and make a list of additional vocabulary Bailey will
from the main page, which then took her to another screen, need to be a successful communicator.
where she selected either breakfast, lunch, dinner, or snacks.
Once she selected an item on this page, she was taken to 3. Discuss how the role of the assistive technology team
another set of icons, where she chose the particular food in Bailey’s case will change and grow now that Bailey
item she would like to have. has a communication device. What do you see as the
role of each team member as Bailey moves through
1. Working in groups, visit the websites for manufactur-
the next few years of school? Specifically, answer the
ers of high tech AAC devices such as DynaVox and
following:
Prentke Romich. Review the communication devices
on the websites and discuss the pros and cons of each a. Who will make sure vocabulary is updated on a
device for a child such as Bailey. Develop a table regular basis?
to compare and contrast the features of 5 devices b. What will be the expectation for home use if
that your group believes could provide Bailey with Bailey is already able to use nonverbal strategies to
adequate vocabulary and a feasible access method for communicate at home?
her current and future needs. c. Who will provide caregiver training on the fea-
2. Explain how the initial setup described previously tures and maintenance of the device?
(multiple pages with a few choices on each page) d. If the device needs to be sent out for repairs, what
would affect the physical, cognitive, linguistic, and is the backup plan to allow Bailey to communicate
time load factors for Bailey. while waiting for repairs to be made to the device?
After completing a few weeks of the trial, Bailey’s occu-
pational therapist informs the team that she feels it might
 Pediatric Professional Role Play: A Case for Assistive Technology 187

REFERENCES TEACHING RESOURCE

1. Beukelman DR, Mirenda P. AAC: Supporting Children and Adults Buzolich M. Collaborative Teaming for students who require AT/
with Complex Communication Needs. 4th ed. Baltimore, MD: Paul H. AAC. Augmentative Communication & Technology Services
Brookes; 2013. Web site. http://www.acts-at.com/resources/A AC-PROGR AM-
2. Millar DC, Light JC, Schlosser RW. The impact of augmentative and SUPPORT/Buzolich%20Collaborative%20Teaming.pdf. Accessed
alternative communication intervention on the speech production of December 11, 2017.
individuals with developmental disabilities: A research review. J Speech
Lang Hear Res. 2006;49:248-264.
3. Romski M. Augmentative communication and early intervention:
Myths and realities. Infants and Young Children. 2005;18(3):174-185.
4. King TW. Assistive Technology: Essential Human Factors. Needham
Heights, MA: Allyn & Bacon; 1999.
Appendix E
Evaluating and Using
Professional Websites
Catherine Rush Thompson, PT, PhD, MS

with special needs? If so, provide your rationale for recom-

WEBSITE EVALUATION mending it. If not, describe what is missing based upon your
evaluation of the resource.
It is important to evaluate each source of information to
determine whether it is authentic, accurate, objective, and
current. The following sites offer rubrics and other resources
for evaluating websites: PROFESSIONAL WEBSITES FOR
• Cornell University Library. Evaluating Web Pages:
Questions to Consider: Categories. http://guides.
PEDIATRIC THERAPISTS
library.cornell.edu/evaluating_Web_pages. Accessed • American Physical Therapy Association: www.apta.org
March 25, 2017.
• American Occupational Therapy Association:
• University of Maryland. University Library www.aota.org
Guides: JOUR202 - Editing for the Mass Media
• American Speech-Language-Hearing Association:
- Evaluating Websites. http://lib.guides.umd.edu/c.
www.asha.org
php?g=327107&p=2195123. Published Nov 9, 2017.
Accessed December 11, 2017.
• University of Southern Maine. USM Libraries. Checklist
for Evaluating Web Resources. https://usm.maine.edu/ WEBSITES FOR FAMILIES AND
library/checklist-evaluating-web-resources. Publication
2017. Accessed December 11, 2017.
PROFESSIONALS
Select a relevant topic of interest, find a website featur- • American Academy of Pediatrics: Healthy Children:
ing this topic, and review the website using evaluation cri- https://w w w.healthychildren.org/English/Pages/
teria suggested above. Would you recommend this site as a default.aspx
good source of information for your interprofessional team?
Would you recommend it for use by families of children

Thompson CR. Pediatric Therapy:

An Interprofessional Framework for Practice (pp 189-190).
- 189 - © 2018 SLACK Incorporated.
190 Appendix E

• American Association on Intellectual and • National Institutes for Mental Health: Child and
Developmental Disabilities: https://aaidd.org/home Adolescent Mental Health: https://www.nimh.nih.
• The Arc: For People with Intellectual and Developmental gov/health/topics/child-and-adolescent-mental-health/
Disabilities: www.thearc.org/ index.shtml
• Center for Disease Control and Prevention: Children • National Association of Councils on Developmental
Diseases: https://www.cdc.gov/parents/children/diseas- Disabilities: http://nacdd.org/
es_conditions.html • Parents Helping Parents: http://www.php.com/
• Easter Seals: http://www.easterseals.com • Pathways: Information on Typical and Atypical Child
• Family Voices: http://www.familyvoices.org/ Development: www.pathways.org
• Federation for Children with Special Needs: • Pediatric Therapy Network:
http://fcsn.org/ http://www.pediatrictherapynetwork.org/
• Friendship Circle: http://www.friendshipcircle.com/ • Special Needs Alliance:
• Goodwill Industries: http://www.goodwill.org/ http://www.specialneedsalliance.org/
• Medscape: Look for “Pediatrics” http://emedicine.med- • Special Olympics: http://www.specialolympics.org/
scape.com/ • United Cerebral Palsy: http://ucp.org/
Appendix F
Educational Resources
Videos and Books Related to Pediatric Therapy
Catherine Rush Thompson, PT, PhD, MS

RECOMMENDED BOOKS RELATED TO Occupational Therapy

• Best Practices for Occupational Therapy in Schools by
PEDIATRIC THERAPY Gloria Frolek Clark and Barbara Chandler
• Collaborating for Student Success: A Guide for School-
Interprofessional Reference Books Based Occupational Therapy (Second Edition) by Barbara
• 1001 Pediatric Treatment Activities: Creative Ideas for Hanft and Jayne Shepherd
Therapy Sessions by Ayelet H. Danto • Kids Can be Kids: A Childhood Occupations Approach by
• Early Childhood by Barbara Chandler Shelly J. Lane and Anita C. Bundy
• Imaging in Pediatrics (First Edition) by Arnold Carlson • Occupational Therapy Evaluation for Children: A Pocket
Merrow and Selena L Hariharan Guide (Second Edition) by Shelley E. Mulligan, PhD,
• Neonatal and Pediatric Pharmacology: Therapeutic OTR
Principles in Practice by Jacob V. Aranda, MD, PhD, • Occupational Therapy for Children and Adolescents
FRCP(C) and Sumner J. Yaffe, MD (Seventh Edition) by Jane Case-Smith EdD, OTR/L,
• Pediatric Rehabilitation: Principles and Practice (Fifth FAOTA and Jane Clifford O’Brien, PhD, OTR/L
Edition) by Michael A. Alexander, MD and Dennis J. • Pediatric Occupational Therapy and Early Intervention
Matthews, MD by Jane Case-Smith, EdD, OTR/L, FAOTA
• Pediatrics (Series: Rehabilitation Medicine Quick • Pediatric Occupational Therapy Handbook: A Guide to
Reference) by Maureen R. Nelson, MD Diagnoses and Evidence-Based Interventions by Patricia
Bowyer, EdD, OTR/L, BCN and Susan M. Cahill,
MAEA, OTR/L

Thompson CR. Pediatric Therapy:

An Interprofessional Framework for Practice (pp 191-193).
- 191 - © 2018 SLACK Incorporated.
192 Appendix F

Physical Therapy • CONNECT Modules: Instructor Supports: http://

community.fpg.unc.edu/connect-modules/instructor-
• Campbell’s Physical Therapy for Children Expert Consult supports. CONNECT (The Center to Mobilize Early
(Fifth Edition) by Robert J. Palisano, Margo Orlin, and Childhood Knowledge) provides videos and activities
Joseph Schreiber for an evidence-based practice approach to professional
• Pediatric Physical Therapy (Fifth Edition) by Jan Tecklin development.
• Peds Rehab Notes: Evaluation and Intervention Pocket • CONNECT Videos: https://www.youtube.com/playlist
Guide by Robin L. Dole ?list=PLBB64DAC64304E785. The Center to Mobilize
• Physical Therapy for Children (Fourth Edition) by Suzann Early Childhood Knowledge (CONNECT) created a
K. Campbell, Robert J. Palisano, and Margo Orlin series of 139 web-based modules for national educa-
tional use by early childhood instructors and learners,
Speech-Language Pathology including Foundations of Inclusion Birth to Five and
Early Intervention: A Routines-Based Approach—Part
• Communication Assessment and Intervention with Infants 1: Traditional vs Routines.
and Toddlers by Barbara Weitzner-Lin
• “Early Intervention: Helping babies with visu-
• Helping Children to Improve Their Communication al impairments” (https://www.youtube.com/
Skills: Therapeutic Activities for Teachers, Parents and watch?v=6rbHOAtBNew)
Therapists by Deborah Plummer
• “Early Intervention Home Visits” (https://www.you-
• Intervention in Child Language Disorders by Ronald B. tube.com/watch?v=8fOJGmIdj0c)
Hoodin
• Language and Communication Disorders in Children Early Childhood Special Education
(Sixth Edition) by Deena K. Bernstein
• “Challenging Behavior in Young Children” (https://
www.youtube.com/watch?v=8eCfnrGu5xo)
VIDEOS RELATED TO • “Peek into early childhood education: Meet Billy”
(https://www.youtube.com/watch?v=a0NAptuWZz4)
PEDIATRIC THERAPY • “Lee Ann Britain Infant Development Center”(https://
www.youtube.com/watch?v=CKeByRhRGxE) The Lee
These following videos are posted on YouTube and pro- Ann Britain Infant Development Center is dedicated to
vide audiovisual information that may help in demonstrat- serving children with developmental disabilities from
ing key concepts addressed in the various practice settings. birth to 6 years of age. The Lee Ann Britain Infant
Note that these videos were produced and posed with vol- Development Center uses a unique program that gets
untary permission by those who appear in the video and are siblings and parents involved in the process of therapeu-
publicly available. These videos may be used, unaltered, for tic treatment and education.
professional development (with appropriate citation). • “Go Baby Go! - Mobility for kids with disabilities”
(https://www.youtube.com/watch?v=kW_gzM3iGlM)
Neonatal Intensive Care
• “Days in the Life: NICU” (https://www.youtube.com/ Elementary School
watch?v=Zt7R-4LmusY)
• “ABA Autism Classroom Case Study 2008” (https://
• “How do Neonatal Therapists work with OT/PT/ www.youtube.com/watch?v=w9N0_7D_Re8)
SLP in NICU?” (https://www.youtube.com/
• “Engaging Families and Creating Trusting Partnerships
watch?v=ovDJeuoN7Us)
to Improve Child and Family Outcomes” (https://www.
• “Neonatal Intensive Care for Premature Baby” (https:// youtube.com/watch?v=fvwVOi_8Xd0)
www.youtube.com/watch?v=AFGkNAeE4Wo&list=P
LotU4X0mUnSXwscLg7NIBk6RcH0uAvX8C&ind High School
ex=7)
• “My Transition Story” (https://www.youtube.com/
Early Intervention watch?v=WXqkuZkJ5Xo)
• “Popular Special Education Videos” (https://www.you-
• “10 Early Signs of Autism” (https://www.youtube.com/
tube.com/playlist?list=PLIXtN8GZ_10ypqBORZLMf
watch?v=r1CqboCzxSc)
z_p-fp_J6h2F)
 Educational Resources: Videos and Books Related to Pediatric Therapy 193

Medical Care (Inpatient, Outpatient, Accommodations and Modifications

Rehabilitation, and Clinic Care) • “Accommodations and Modifications for Students
• “Brachial Plexus Center/Cincinnati Children’s” (https:// with Disabilities” (https://www.youtube.com/
www.youtube.com/watch?v=q_kzRJVZ4S8) watch?v=O0xdaCEqrU0)
• “Burn Care Splinting” (PT/OT splinting for burn patients) • “iPads for Special Needs” (https://www.youtube.com/
(https://www.youtube.com/watch?v=2VMlvntxSco) watch?v=So2eDnKosJc)
• “Child Pain Management” (https://www.youtube.com/ • “iPads & Autism at Manhattan Childrens Center by
watch?v=wBpPwGpkiIY) Andrew J Parsons 2010” (https://www.youtube.com/
watch?v=OZmpQj7WhBc)
• “Pediatric Occupational and Speech Therapy” (https://
www.youtube.com/watch?v=PGb3hFFXwfw) • “Kids Like Me (with disabilities)—I believe!” (https://
www.youtube.com/watch?v=wJQQtM6240s)
• “Physical Therapy and Occupational Therapy” (https://
www.youtube.com/watch?v=iXu0ntBTEXg)
• “What is Feeding Therapy? Sample Session from JCFS’
Integrated Pediatric Interventions” (https://www.you-
tube.com/watch?v=X2nGk2DoOt8)