Transcript Early Intervention Seminar 3

Physiotherapy with Children
Movement is important for children’s
development and learning
☺Physiotherapy with Children
☺Significant Gross Motor Development
Milestones (GMDM)
☺Red Flags
☺What to encourage?
Physiotherapy with Children
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Physiotherapy=‘physical’ + ‘treatment’
Assessment
Formulate problem list
Block of therapy
Refer to other services
Review and home program
Discharge as appropriate
Areas that Physiotherapist work on
with children
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Gross motor development
Movement patterns
Postures
The baby develops dramatically in
his/her gross motor skills in the first
year of life
Significant GMDM (6wk-18m)
Lift head when on tummy……3m
Rolling………………………….4-6m
Sitting…………………………..6-8m
Crawling……………………….8-10m
Standing……………………….9-12m
Walking unsupported…………9-18m
Tummy play time
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Start as early as possible, soon after birth
Best before feed, after bath or when well alert
A few times a day
Rolling (4-6m)
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First exciting mobility on the floor
Sitting (6-8m)
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Sit up to see the world
Crawling (8-10m)
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Set the foundation for coordination tasks
Standing and walking (9- 18m)
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Feel tall and big
Red flag when babies are
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looking to one direction
most of the time
– Habit
– Muscle tightness at the
neck
– Flattened on one side of
the back of head
Further flattening of head
which lead to asymmetrical
head shape (positional
plagiocephaly)
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Born pre-mature
– Born equal or less than 34weeks
– Eg. Baby born at 32wks, when they are 8m, we
should expect that the GM dev. will be around 6m
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Stiff
– High muscle tone, tight muscles
– Arching of the body, hard to bend the arms and
legs
– Difficulty in dressing, changing nappies, sitting up
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Floppy
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Low muscle tone
Prefer to lay on their back
Dislike tummy time
Not eager to move around
Sit with a round back
Lack of opportunity
– Consistent to be put in certain position
– Too much time in baby walker, means inadequate
time for tummy play time
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‘W’ sitting
– sit between feet with knees bent
develop pigeon toe walking pattern
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Constantly stand or walk on tip toes
– tight calves, high calf muscle tone, habit
delay in walking, shortening of calves
What to encourage?
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Facilitate baby to look to both directions
Provide plenty of tummy play time
Perform arms and legs exercises after nappy
change
Facilitate crawling instead of bottom shuffling
Encourage walking along furniture and
negotiate obstacles
Cross-legged sitting instead of ‘W’ sitting
posture
Significant GMDM (18m-3yr)
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Development of balance and emerge of
new skills
Squatting well…………..18m
Jumping on a spot ……..3yr
Running safely………….3yr
Red Flag when children are
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Falling over excessively
– poor balance, severe pigeon toed, perceptual
issues
injuries
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Walking on tip-toes (80-90% of the time)
– tight calves, high calf muscle tone, habit
sore calves, decrease walking tolerance,
shortening of calves
What to encourage?
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Using out-door
equipment
– Swings, slides, climbing
frame, tunnel
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Walking on balance
beam (20-30cm wide)
Chasing
Jumping in the sand-pit
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Riding tricycle
Kicking and
throwing balls
Significant GMDM (3-5yr)
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Development of dynamic balance and
refinement of gross motor skills
Jumping from height safely….5yr
Running efficiently……………5yr
Stairs walking………………....adult form
Balance on 1leg………………5s for 5yr old
Red Flag when children are
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Falling over on a flat surface
– Poor balance, pigeon toed
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Moving with awkward movements
– Arms and legs looks awkward when the child is
running or jumping
– Poor balance/coordination
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Having difficulty to stand up from floor
– Weak trunk muscles
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Avoiding physical activities
– Low muscle tone, vestibular dysfunction,
perceptual issues
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Tiring quickly
– Low muscle tone
What to encourage?
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Walking on narrow
beam (10-15cm wide)
Kicking and throwing
balls to target
Simon says
Run and freeze game
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Using out-door
equipment
– Swings, slides,
climbing frame,
tunnel
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Riding bicycle
Jumping on bouncy
surface
Any doubts??
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Refer to the Queensland Health
Developmental check list
www.health.qld.gov.au/child&youth/factsheets
Physiotherapy services
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Contact your local community health centre,
developmental assessment team or hospital
Private Paediatric Physiotherapy services can
be obtained through
– Australian Physiotherapy Association
www.physiotherapy.asn.au
Queensland branch office (07) 3423 1553
– Yellow page
Occupational Therapy with
Children
What is Occupational Therapy??
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Common belief that OTs help people
return to work following injury or illness.
This is only part of the picture.
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“Occupation” actually refers to any activity
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that you do during the day
• Self care activities
• Work and productive activities (paid/unpaid)
• Leisure activities
Occupation for children
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Self care skills – depending on their age
can include being able to self feed,
dress themselves, or be toilet trained.
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Children learn and develop most of their
skills through play. Therefore for
children work and play are the same
thing
Skills OTs typically work on with
children
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Fine motor skills
Visual perceptual and visual motor skills
Play skills
Sensory processing
Self care skills
Fine motor skills
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This is using your hands and fingers.
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These skills allow you to open a jar,
undo your shoe laces, do up a button
and use a pencil, etc etc.
Visual perceptual (VP) and Visual
motor integration (VMI) skills
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Visual Perception is the brain
interpreting what the eyes see.
– Recognising own name
– Judging the right way around to put clothes on
– Knowing which way to hold a book (even if just
looking at the pictures)
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Visual Motor integration is doing
something in response to what you see.
– Draw a picture
– Do a Puzzle
Play Skills
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This includes a range of skills, from
basic exploration of toys to more
creative play:
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Cause and effect
Teddy/doll play
Object Substitution
Role playing and story telling
Playing with peers
Sensory Processing
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There are the five typical senses
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There is also Proprioception (sense of
body awareness) and Vestibular (sense
of movement)
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OTs tend to look more at how sensory
input impacts on the child as a whole.
Self Care Skills
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Feeding
• Independent finger feeding
• Use of cutlery
• Drinking from a cup
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Dressing
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Toileting (note: issues with persistent bed wetting or soiling
tend to be managed by OTs in hospital settings).
RED FLAGS
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All children develop at their own pace
and have their own activity preferences.
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When do you know a child is having a
difficulty??
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See website at end of presentation for
checklists.
Fine motor red flags
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6months
• No hand or arm use at all.
• A marked difference between the use of the left
and right hands.
• Not letting go of toys, even when finished
playing with it.
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12 months
• Still using whole hand to pick up objects, rather
than attempting with fingers first.
• Not using two hands together.
Fine motor red flags cont…
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18 months
• Not stacking blocks
• Cannot use a spoon for feeding
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2 years
• Not interested in pencils
Fine motor red flags cont…
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3 to 4 years
• Poor pencil skills (compared with other children
the same age)
• Refuses or avoids fine motor activities
• Cannot use a fork
• 4 years – not showing a hand preference (esp.
if to start prep in the next year).
VP and VMI red flags
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6 months
• not reaching for toys
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12 months
• poor ability to self feed (hand to mouth feeding)
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18 months
• unable to use simple insert puzzles or shape
sorters
VP and VMI red flags cont…
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2 years
• Unable to copy horizontal or vertical lines
(when first drawn by an adult)
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3 to 4 years
• Not drawing simple pictures (may not look like
anything but they should be able to tell you
what they have drawn)
Play red flags
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6 months
• Does not enjoy sensory play (toys with noise,
lights and/or texture)
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12 months
• Does not engage in container play
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18 months
• Does not understand simple cause and effect
play
Play red flags cont…
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2 years
• No imaginary play (pretend play with
dolls/teddy or imitating adults)
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3 to 4 years
• No imaginary play or very immature play
• No cooperative play with peers
Sensory Processing
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All children need more sensory input
than adults, therefore they seem to be
constantly seeking input.
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Sensory processing issues are only a
problem if they impact negatively on the
activities children either need, or want,
to do.
Sensory Processing red flags
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When a little feels like a lot (overresponsive)
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Want to wash hands +++ or avoids messy play.
Does not like ++ noise
Avoids rough and tumble play
Does not tolerate other children coming too
close.
• Poor eating – limited range of foods
• Tends to be very easily upset and over-reacts
to situations
Sensory Processing red flags cont…
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When a lot feels like a little (underresponsive
• Constantly “on the go”
• Seeks messy, noisy and/or rough and tumble
play.
• Alternatively may need a lot of input to get
going and may appear quite passive.
• Can be intrusive into others personal space
• Can have poor attention
Self Care red flags
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12 months
• Not self feeding
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2 years
• Not using cutlery; Not drinking from a cup
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3 to 4 years
• Not able to manage clothes for toileting
• Not dry by day (by 4 years)
OT services
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QLD Health OT services vary from district
to district. Contact your local community
health centre or hospital for details on
services
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It is important to know the eligibility criteria
– some services need GP or Paediatrician
referrals, while others take self referral.
OT services cont…
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Private OT services
• Yellow pages
• Contact OT Australia QLD on 3397 6744
Early Intervention & Speech
Pathology
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Children are spending longer hours in
child care than ever before.
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The quality of the interactions they have
at child care can make a difference to a
child’s communication development
Effective communication skills mediate
success in all social relationships
The Primary means of establishing and
maintaining social relationships is through the
use of language
Recent studies of the impact of adult-mediated
strategies in day care and preschool settings
have been shown to improve communication
for children with delayed or disordered
language skills
You can, and do, make a huge
difference in the lives of the
children in your care.
– What is a Speech Pathologist
– ‘Red Flags’: language development
especially under <3yrs
– Communication styles: children
– Strategies to aid communication
• Observe wait and listen
• Face to face communication
What is a “Speech Pathologist”?
Same as a ‘Speech Therapist’
 Treat children who stutter and lisp
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But, we also do a whole lot more!!
A Speech Pathologist:
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Assesses and treats children and adults
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Speech (sound production)
Fluency (stuttering)
Voice
Feeding
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Language: receptive and expressive
– Semantics (word meaning)
– Syntax (grammatical structure)
– Pragmatics (social use of language)
These areas of difficulty may exist as
separate conditions OR may be part of a
more global/developmental problem.
Public Speech Pathology:
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Some services have long waiting lists.
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Specific inclusion criteria e.g. In the
West Moreton District we prioritise
children under 3 y.o. seen < 3months
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The earlier a referral is made the better
Paed Speech at WMSBD: < 3 y.o
If referral accepted
Questionnaires returned
Waiting list < 3 months
Full assessment
Referral to other disciplines
Hanen program
Monitor and review
Block of treatment
Management
Referral to other agency
Referrals – generally
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Generally parents can refer to
Community Health Centres
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Generally parents need to get a GP’s
referral to be referred to a Hospital
Speech Pathologist (varies a lot)
Prevalence of SLI
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Parents and teachers are very accurate
at identifying children with difficulties
About 16.3% of all children will have a
communication difficulty
47.5% will have difficulties in more that
one communication area
Comorbidities are common (gross or
fine motor difficulties)
Only 50% of children with a
communication difficulty will
ever see a Speech Pathologist
Developmental Continuums
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Check your text books about the
milestones for babies, toddlers and
young children.
www.health.qld.gov.au/child&youth/facts
heets
‘Red Flags’
Delay/disorder/difference
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Some researchers saying that:
– Delay = <3yrs
– Disorder = >3yrs
Outcomes for children with SLI:
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Children with language disorder at 5yrs have
poor outcomes:
• learning difficulties
• antisocial adolescent behaviour
• limited vocational opportunities
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Children with speech only difficulties have
similar outcomes as children with normal
speech and language development.
Take home message:
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It is important to be on the look out for
the indicators of language delay (ages
1-3yrs) as these children are most at
risk of the life long implications of
language disorder.
Red Flags - 12mths
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Definite indicators of children at risk of
language delay before they start talking
Look for:
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Babbling
Pragmatic skills
Language comprehension
Play skills
Babbling – (12 months cont)
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The more the better
Why?
• Sound practice (basis of early words)
• Increased response from care givers
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Listen for:
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amount
number of different sounds
reduplicated and variegated
accuracy of production
Pragmatic Skills (12 months cont)
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Indicates social motivation
Look out for:
– eye gaze (engaging in eye contact)
– social greetings (hello and goodbye)
– facial expression (showing they enjoy
interaction)
– requesting and protesting (using pointing)
Language Comprehension (12 m)
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Usually develops before expression
Age appropriate comprehension is a
positive indicator that language skills
will develop
Delays of >6mths indicates a more
persistent difficulty
Red Flags - 2yrs
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10-15% of 2yos will have an obvious
delay in language development
Look for:
– delayed language comprehension
– restricted vocabulary
– word combinations
– speech
Language comprehension – 2 y.o
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At 2yrs a child’s language
comprehension should be on par with
same aged peers
Any delay indicates a child is at risk
A delay >6mths is a strong indicator of a
persistent or more global difficulty
Restricted Vocabulary – 2 y.o.
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Expect a child at 2yrs to have a
vocabulary of more than 50 words
Word combinations – 2 years
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Expect a child at 2yrs to be using some
two word combinations
Speech at 2 years old
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26-50% intelligible
wide range of sound errors still
acceptable
look out for:
– vowel errors
– use of /h/ for other consonants
Red Flags - 3yrs
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60% of delayed 2yos will have
recovered
at 3yo, the group of delayed children is
smaller and more at risk - ‘disorder’
speech should be 73% intelligible
– ok if intelligibility decreases in complex
sentences
– range of errors still acceptable
Refer at 3yrs if:
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A child is unintelligible
a child doesn’t use or understand
concepts, words or sentences
a child doesn’t engage with other
children in a social/communicative way
a child isn’t interested in concepts, how
and why, or stories (including retell)
4-6yrs
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Be guided by charts/developmental
checklists
at this age, it is increasingly unlikely that
a child will ‘outgrow’ their difficulties
at risk of ongoing difficulties at school
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Don’t delay referrals
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Have a little think about…….
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Which children do you most enjoy
interaction with? (what are their
conversational styles?)
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Which children do you interact with the
least? (What are their conversational
styles?)
Children’s interaction styles
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Reluctant/shy style
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Passive style
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Own Agenda
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Sociable
Adults have their own styles too!!
I really hate it when I am talking
with someone and they…..
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Don’t listen to what I’m saying
Interrupt
Don’t look at me
Take over the conversation and I can’t
get a word in
Just keep telling me what to do
Observe
Wait
Listen
Give a reason to communicate &
wait!
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Wait and see what the child will do:
avoid the helper role
Place a desired object in view but out of
reach
Introduce a hard-to-operate object
Offer things bit by bit
Do the unexpected
A VERY simple way to connect…
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BE FACE TO FACE!!! 
Think about…
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Identify four children from your class
that display the four different
conversational styles.
If you have a concern about a child..
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Can be difficult but definitely worth
approaching the parent!
Before you approach parent:
1. Have a checklist with you. Developmental
checklists can be obtained from
www.health.qld.gov.au/child&youth/factsheets
2. Know what services are available
- phone local hospital, community health
service, yellow pages for private SPs.
Discussing with parents… con’t
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Develop rapport first
Maybe first time parent has had anyone say
something might be wrong with their child
Refer back to checklist – keeps it objective
Address with concern for the child
Give parents time to think about it/discuss
with partner
Follow up. Could suggest that they get an
opinion because better to be safe than sorry.
Discussing with parents… con’t
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Sometimes can take a while for a parent
to ‘come ‘round’.
Sometimes they don’t turn up for us OR
don’t come back after first session, but
then turn up again e.g. 12 months later
Most parents will appreciate your
interest in their child if done
compassionately.
Teacher Talk Workshop
International Speaker: Anne
McDade, Speech Pathologist,
Hanen Trainer
 Encouraging Language
Development in Early Childhood
Settings
 Saturday 1st September
 Wilston, Brisbane
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Teacher Talk Seminar cont
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Audience: Teachers & Teacher Aides in
Child Care Settings, SEDU, Prep
$110 per person, includes workbooks,
lunch, morning & afternoon tea
Contact for more information:
[email protected]