physiotherapy with children. movement is important for children’s development and learning

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 Physiotherapy=‘physical’ + ‘treatment’

Assessment

Formulate problem list

Block of therapy

Review and home program

Refer to other services

Discharge as appropriate

Areas that Physiotherapist work on with children

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……3mRolling………………………….4-6mSitting…………………………..6-8mCrawling……………………….8-10mStanding……………………….9-12mWalking unsupported…………9-18m

Tummy play time

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)

First exciting mobility on the floor

Sitting (6-8m)

Sit up to see the world

Crawling (8-10m)

Set the foundation for coordination tasks

Standing and walking (9- 18m)

Feel tall and big

Red flag when babies are

looking to one direction most of the time– Habit– Muscle tightness at the

neck– Flattened on one side of

the back of headFurther flattening of head

which lead to asymmetrical head shape (positional plagiocephaly)

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 Stiff

– High muscle tone, tight muscles– Arching of the body, hard to bend the arms and

legs – Difficulty in dressing, changing nappies, sitting up

Floppy– 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

‘W’ sitting– sit between feet with knees bent

develop pigeon toe walking pattern Constantly stand or walk on tip toes

– tight calves, high calf muscle tone, habit

delay in walking, shortening of calves

What to encourage?

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)

Development of balance and emerge of new skillsSquatting well…………..18mJumping on a spot ……..3yrRunning safely………….3yr

Red Flag when children are

Falling over excessively– poor balance, severe pigeon toed, perceptual

issues

injuries 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?

Using out-door equipment– Swings, slides, climbing

frame, tunnel

Walking on balance beam (20-30cm wide)

Chasing Jumping in the sand-pit

Riding tricycle Kicking and throwing

balls

Significant GMDM (3-5yr)

Development of dynamic balance and refinement of gross motor skillsJumping from height safely….5yrRunning efficiently……………5yrStairs walking………………....adult formBalance on 1leg………………5s for 5yr old

Red Flag when children are

Falling over on a flat surface– Poor balance, pigeon toed

Moving with awkward movements– Arms and legs looks awkward when the child is

running or jumping– Poor balance/coordination

Having difficulty to stand up from floor– Weak trunk muscles

Avoiding physical activities– Low muscle tone, vestibular dysfunction,

perceptual issues Tiring quickly

– Low muscle tone

What to encourage?

Walking on narrow beam (10-15cm wide)

Kicking and throwing balls to target

Simon says Run and freeze game

Using out-door equipment– Swings, slides,

climbing frame, tunnel

Riding bicycle Jumping on bouncy

surface

Any doubts??

Refer to the Queensland Health Developmental check list

www.health.qld.gov.au/child&youth/factsheets

Physiotherapy services

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.auQueensland branch office (07) 3423 1553

– Yellow page

Occupational Therapy with Children

What is Occupational Therapy??

Common belief that OTs help people return to work following injury or illness.

This is only part of the picture.

“Occupation” actually refers to any activity that you do during the day

• Self care activities• Work and productive activities (paid/unpaid)• Leisure activities

Occupation for children

Self care skills – depending on their age can include being able to self feed, dress themselves, or be toilet trained.

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 Fine motor skills Visual perceptual and visual motor skills Play skills Sensory processing Self care skills

Fine motor skills

This is using your hands and fingers.

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 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)

Visual Motor integration is doing something in response to what you see.

– Draw a picture– Do a Puzzle

Play Skills

This includes a range of skills, from basic exploration of toys to more creative play:

• Cause and effect• Teddy/doll play• Object Substitution• Role playing and story telling• Playing with peers

Sensory Processing

There are the five typical senses

There is also Proprioception (sense of body awareness) and Vestibular (sense of movement)

OTs tend to look more at how sensory input impacts on the child as a whole.

Self Care Skills

Feeding• Independent finger feeding• Use of cutlery• Drinking from a cup

Dressing

Toileting (note: issues with persistent bed wetting or soiling tend to be managed by OTs in hospital settings).

RED FLAGS All children develop at their own pace

and have their own activity preferences.

When do you know a child is having a difficulty??

See website at end of presentation for checklists.

Fine motor red flags 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.

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…

18 months• Not stacking blocks• Cannot use a spoon for feeding

2 years• Not interested in pencils

Fine motor red flags cont…

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

6 months • not reaching for toys

12 months• poor ability to self feed (hand to mouth feeding)

18 months • unable to use simple insert puzzles or shape

sorters

VP and VMI red flags cont…

2 years• Unable to copy horizontal or vertical lines

(when first drawn by an adult)

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

6 months• Does not enjoy sensory play (toys with noise,

lights and/or texture)

12 months• Does not engage in container play

18 months• Does not understand simple cause and effect

play

Play red flags cont…

2 years• No imaginary play (pretend play with

dolls/teddy or imitating adults)

3 to 4 years• No imaginary play or very immature play• No cooperative play with peers

Sensory Processing

All children need more sensory input than adults, therefore they seem to be constantly seeking input.

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

When a little feels like a lot (over-responsive)

• 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…

When a lot feels like a little (under-responsive

• 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

12 months• Not self feeding

2 years• Not using cutlery; Not drinking from a cup

3 to 4 years• Not able to manage clothes for toileting• Not dry by day (by 4 years)

OT services

QLD Health OT services vary from district to district. Contact your local community health centre or hospital for details on services

It is important to know the eligibility criteria – some services need GP or Paediatrician referrals, while others take self referral.

OT services cont…

Private OT services• Yellow pages• Contact OT Australia QLD on 3397 6744

Early Intervention & Speech Pathology

Children are spending longer hours in child care than ever before.

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

But, we also do a whole lot more!!

A Speech Pathologist:

Assesses and treats children and adults

Speech (sound production) Fluency (stuttering) Voice Feeding

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:

Some services have long waiting lists.

Specific inclusion criteria e.g. In the West Moreton District we prioritise children under 3 y.o. seen < 3months

The earlier a referral is made the better

Paed Speech at WMSBD: < 3 y.o

If referral accepted

Questionnaires returned Referral to other disciplines

Hanen programWaiting list < 3 months

Full assessment

Management

Monitor and review

Block of treatment

Referral to other agency

Referrals – generally

Generally parents can refer to Community Health Centres

Generally parents need to get a GP’s referral to be referred to a Hospital Speech Pathologist (varies a lot)

Prevalence of SLI

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

Check your text books about the milestones for babies, toddlers and young children.

www.health.qld.gov.au/child&youth/factsheets

‘Red Flags’

Delay/disorder/difference

Some researchers saying that:

– Delay = <3yrs– Disorder = >3yrs

Outcomes for children with SLI:

Children with language disorder at 5yrs have poor outcomes:

• learning difficulties• antisocial adolescent behaviour• limited vocational opportunities

Children with speech only difficulties have similar outcomes as children with normal speech and language development.

Take home message:

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

Definite indicators of children at risk of language delay before they start talking

Look for:• Babbling• Pragmatic skills• Language comprehension• Play skills

Babbling – (12 months cont)

The more the better Why?

• Sound practice (basis of early words)• Increased response from care givers

Listen for:• amount• number of different sounds• reduplicated and variegated• accuracy of production

Pragmatic Skills (12 months cont)

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)

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

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

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.

Expect a child at 2yrs to have a vocabulary of more than 50 words

Word combinations – 2 years

Expect a child at 2yrs to be using some two word combinations

Speech at 2 years old

26-50% intelligible wide range of sound errors still

acceptable look out for:

– vowel errors– use of /h/ for other consonants

Red Flags - 3yrs

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:

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

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

Don’t delay referrals

Have a little think about…….

Which children do you most enjoy interaction with? (what are their conversational styles?)

Which children do you interact with the least? (What are their conversational styles?)

Children’s interaction styles

Reluctant/shy style

Passive style

Own Agenda

Sociable

Adults have their own styles too!!

I really hate it when I am talking with someone and they…..

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!

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…

BE FACE TO FACE!!!

Think about…

Identify four children from your class that display the four different conversational styles.

If you have a concern about a child..

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

• 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

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

Teacher Talk Seminar cont

Audience: Teachers & Teacher Aides in Child Care Settings, SEDU, Prep

$110 per person, includes workbooks, lunch, morning & afternoon tea

Contact for more information:

alison_hewitt@health.qld.gov.au