east sussex children’s integrated · orthotic provision for children on active cit es caseload...

Version 5: Jan 2019 1

Review Date: Jun 2019

East Sussex Children’s Integrated

Therapy & Equipment Service

Referral Guidance



CONTRACT In Scope

REFERRALS ACCEPTED

Age Criteria:

Children and Young people 0-18 years –but transition to adult services would occur within that time at an appropriate age and stage.

16 - 19 (up until young person 19 – last day of 18) if in full time education in East Sussex.

Full time education includes post 16 colleges that are equivalent to secondary school education.

For specific colleges that have alternative therapy provision as part of their offer they would meet the needs of the children.

Moderate to severe global development delay

Neurological conditions affecting development and posture e.g. cerebral palsy, muscular dystrophy

Rehabilitation following multi-level surgery who are known to CITES

Acquired brain injury, for example post encephalitis/near drowning NB this does not include intensive rehabilitation and children and young people should be ready for discharge to community therapy services.

Oncology

Palliative care

Syndromes affecting neurological development

Developmental co-ordination disorder (DCD) – subject to DCD pathway criteria

Eating and drinking difficulties relating to neurological developmental disorders.

Respiratory conditions that require teaching of clearing of secretions e.g. cystic fibrosis

Orthotic provision for children on active CITES caseload

ASD diagnostic pathway for all children referred whilst still in primary education

Language – subject to completion of specified programmes in settings and schools

Phonological disorder

Developmental verbal dyspraxia

Voice disorders

Hearing impairment

Cleft palate and non-cleft velo-pharyngeal insufficiency

Dysfluency



Selective mutism

Augmentative and alternative communication

Juvenile idiopathic arthritis

Talipes/Ponseti

Hip dysplasia/Pavlik harness

Severe hypermobility if condition is significantly impacting on gross motor functional ability

Torticollis

Erb’s palsy

Post orthopaedic surgery for children on CITES caseload with pre-existing developmental or neurological condition

Chronic fatigue syndrome/Chronic regional pain syndrome – where children are under the primary care of CAMHS/ primary mental Health Services

Severe sensory processing difficulties in children over 3 years, affecting function in at least 3 defined areas of self-care or activities of daily living. Please note this does not include attention in the classroom.

Serial casting post Bo-tox



Global development delay

Syndromes affecting neurodevelopment

Cerebral palsy

Acquired brain injury

Physiotherapy

Hip dysplasia/ Pavlik harness

Erb’s palsy

Torticollis

Respiratory

Talipes/ Ponseti


Orthotics

Speech and language therapy

Voice

Speech sound delay/disorder

Language delay/ disorder

Fluency/ stammering

Hearing impairment

Selective mutism

Cleft palate

Occupational therapy/ speech and language therapy

Eating and drinking disorders

Autism spectrum disorder

Augmentative/ alternative communication

Occupational therapy

Visual perceptual difficulties

Activities of daily living: self care

Minor and major adaptations

Functional skills affected by sensory difficulties

Physiotherapy/ occupational therapy

Developmental co-ordination disorder

Hypermobility

Equipment

East Sussex Children’s

Integrated Therapy Service

This graphic describes the

children we work with, both

in terms of their diagnosis

and needs.

It shows when the

disciplines might work

together. However two or

more disciplines may not

always be needed.

Sometimes they may be

involved with a child and

family at different times

depending on the child’s

changing needs.

Referral forms are available

from [email protected]

Our standard for referral

acceptance to initial

assessment is 10 weeks.

If a referral is declined we

send a letter to explain why

to the referrer and parent

within 10 working days.



The emphasis of Occupational Therapy is enabling. This means helping children to overcome functional difficulties that affect daily life and may present at home or in the school environment.

Referrals are specified for children who present with significantly delayed motor development which impacts on their daily functioning. This includes children with an underlying neurological condition, motor-planning difficulties, global developmental delay, ASD (where skills are not in line with diagnosis), upper-limb dysfunction, palliative care and life-limiting conditions. There is an expectation that all school-age children access the Jump Ahead programme, designed to address fine/gross motor skill acquisition and Sensory Circuits (sensory-motor programme) at school before a referral is considered.

Postural management Occupational Therapists work closely with Physiotherapists to identify appropriate seating systems or equipment to support 24 hour postural management of children with complex physical disabilities. Seating can range from low level postural support to complex, dynamic modular seating systems. Similarly, Occupational Therapists will work closely with their Physiotherapy colleagues in relation to prescription of sleep systems to ensure correct positioning at night-time.

Activities of daily living Occupational Therapists are able to identify and work with children to identify the underlying difficulties preventing a child from being as independent as possible in areas of self-care. Interventions may be in the form of a programme, advice, direct intervention from an occupational therapist or Integrated Therapy Assistant under the guidance of the treating therapist or by adapting an activity to meet the needs of the child. Interventions may include the following: Dressing, use of techniques such as backward chaining to support skill progression Eating and drinking, e.g. use of cutlery, dycem (non-slip mat), plate-guards and activities

Occupational Therapy Guidance Details



Access to suitable bathing/ toileting facilities

Equipment/ minor adaptations to support daily living

Occupational Therapists may provide equipment to facilitate independence either in the home or to access education. Interventions may include the following: Access to bathing/ showering: bath-lifts, bath-boards, grab rails and shower-chairs Toileting - commode, toilet-frames, specialist modular toileting systems Manual-handling equipment e.g. mobile hoists, transfer-boards, slide sheets

Adaptations (0-18) over 18’s should be referred to Adult Social Care For children with complex physical disabilities or challenging behaviours compromising their safety in the home, there may be a need to adapt the home/ and or school environment. Major adaptations are subject to criteria set out in the Disable Facilities Grant legislation and the budget is held by local councils. Occupational Therapists are responsible for assessing need under this legislation and making clinical recommendations regarding reasonable adaptations to meet a child’s needs. It is not always possible to provide a solution within the grant funding, in such cases the Occupational Therapist will work with the wider multi-agency team to support a family with exploring re-housing options. Motor co-ordination difficulties which severely affect functional daily living a referral will be considered where children have accessed the Jump Ahead programme or Sensory Circuit programme but there are still ongoing difficulties e.g.:

Sequencing movements Spatial awareness Body awareness Motor planning

Evidence is required where a child has been unable to progress and Jump Ahead should be completed a minimum of 3 times a week for 4



academic terms.

Visual perception Visual motor integration impacts on handwriting and letter formation. Please note we do not deliver handwriting programmes but will assess and advise schools regarding implementation of appropriate programmes where applicable. Sensory processing There should be evidence of severe sensory processing difficulties in at least three defined areas of self-care or activities of daily living e.g. using cutlery, managing buttons, dressing, toileting difficulties, pencil grip or personal hygiene. Attention does not count as an activity for daily living. We are not commissioned to provide interventions for children with sensory processing difficulties under age of 3 unless they are under a specialist Tertiary Centre such as Evelina Children’s Hospital or Great Ormond Street Hospital for sensory processing difficulties. Upper-limb Where applicable OT will provide upper-limb programmes to promote function and development of self-care. Complex cases such as children with neurological impairment may be provided with a thumb or wrist splint where appropriate.



Neurological concerns or conditions affecting development please refer in for any of the following:

All children with a new diagnosis of Cerebral Palsy (CP) or showing signs of an evolving motor disorder.

Children moving in to the area with an existing diagnosis of CP who have functional difficulties.

Babies and children presenting with any of the following:

- Abnormal tone

- Asymmetrical movement or unusual movement patterns. W sitting, bottom shuffling and in-toeing are not indications of an

abnormal movement pattern unless abnormal tone is present

- Functional difficulty i.e. difficulty standing or walking and out of line with normal developmental parameters

- Delayed milestones or poor quality of movement


CITES do not deliver intensive rehabilitation. The child should be ready for discharge to community therapy services

Neuromuscular conditions which involve a progressive loss of functional motor skills E.g. Charcot Marie Tooth, Spinal Muscular Atrophy,

metabolic disease, muscular dystrophy)

Treatment and frequency will vary depending on the age and the stage of the child.

All children with a new diagnosis of neuromuscular disease

Early Years children with a plateau of gross motor development for more than 6 months

Children demonstrating a regression or loss of motor skills

Post orthopaedic surgery related to their condition

Physiotherapy Guidance Details



Developmental concerns including moderate to severe global developmental delay and syndromes

Please see developmental table below. Developmental norms are taken from Mary Sheridan, Birth to Five Years. 4th Edition.

Please note: Bottom shuffling is not an abnormal movement pattern. Many children who bottom shuffle instead of crawling to move around the floor start walking at a later age.

Activity Usual milestone Refer to Physiotherapy

Independent floor sitting 5 – 9 months 10 – 12 months

Independent rolling -

From front to back

From back to front

5 – 6 months

6 – 7 months

8 – 10 months (may need referral to

physiotherapy earlier if there is a

concern about head control)

Pulling to stand 7 – 12 months 13 – 16 months

Cruising around furniture 9 – 16 months 17 – 20 months

Independent walking 9 ½ – 17 ½ months (children

who bottom shuffle are usually

delayed in walking 17 – 28

months)

18 ½ months

Jumping 2 ½ - 3 years 4 years (a child who is not jumping

at three is likely to have been

known to the service previously for

delayed walking)



Climbing stairs 3 years (up and down holding a

hand or a rail, usually 2 feet per

step)

4 years (a child who is struggling

with stair climbing at three is likely

to have been known to the service

previously for delayed walking)

Developmental coordination disorder

Children with motor coordination difficulties would be seen either by an Occupational Therapist or Physiotherapist. Please see OT guidance on

motor coordination difficulties for more information (page 6).

Toe walkers

The service would not normally accept referrals for toe walkers with no obvious neurological signs. Children should be referred if:

There is asymmetry

Not possible to achieve 90 degrees at the ankle and there are associated developmental concerns or altered muscle tone. Where there

are no associated concerns, or if the toe walking is intermittent then referral to musculo-skeletal physiotherapy service provided by East

Sussex Healthcare Trust is more appropriate

Toe walking with unusual body posturing or movement

In-toeing

It is very common for young children’s feet to turn in when they walk. This is a common

normal variant.

Referral to physiotherapy is only indicated if there is:

Figure 1



Significant asymmetry

Pain

Metatarsus adductus (Figure 1) where it is not possible to passively correct the position of the forefoot to midline

Orthotics

This provision is only for children already on the CITES caseload. No physiotherapy intervention is indicated in children with flat feet or feet that

turn out. If pain is present then a referral to podiatry services provided by East Sussex Healthcare Trust is advised.

Musculoskeletal problems

Children presenting with musculoskeletal problems should be referred to the appropriate Musculoskeletal (MSK) Physiotherapy Service.

We do accept referrals for babies with musculoskeletal problems this could include the following:

Congenital foot abnormalities e.g. Talipes (club foot)

Preferential head turning (Torticollis)

Hip dysplasia (DDH)

Shoulder dystocia with apparent neuromuscular signs (Erb’s Palsy)

Chronic fatigue syndrome and chronic regional pain syndrome

Children with chronic fatigue syndrome and chronic regional pain syndrome can only be referred to CITES physiotherapy where they are under

the primary care of CAMHS. Physiotherapy can advise on graded exercise and pacing of activities.

Hypermobility

Only refer to CITES physiotherapy when the condition is significantly impacting on gross motor functional ability e.g. causing sleep disturbance

on a regular basis or impacting on attendance at school.




Referrals are accepted for children with functional difficulties at home or at school who require advice on long term management of their

condition.

Respiratory conditions

Please discuss all referrals requiring physiotherapy intervention for respiratory difficulties on an individual basis. Currently CITES is not

commissioned to undertake this work. CITES is presently involved in supporting the Cystic Fibrosis Clinics held by East Sussex Healthcare Trust.



Please note that early years referrals should be made using the CITES referral form available here:

https://www.kentcht.nhs.uk/service/east-sussex-childrens-integrated-therapy-and-equipment-service/ Further evidence e.g. Ages and

Stages Questionnaire, Schedule of Growing Skills, Language Checkers and East Sussex Speech Language and Communication Monitoring Tool

can all be submitted as further evidence for referral.

Schools should refer using the iSEND Front Door. The online referral form is available here:

https://czone.eastsussex.gov.uk/inclusion-and-send/front-door-referrals/

GPs and Paediatricians should refer to our referral guidance for GPs which is available here:

https://www.kentcht.nhs.uk/service/east-sussex-childrens-integrated-therapy-and-equipment-service/

Dysfluency also called stammering or stuttering

Referrals from 27 months after the integrated health review

Many children experience non-fluency when they start to talk in phrases and sentences between 2-3 years. Usually this non-fluency subsides

within 3-6 months. If there is no sign that the fluency is improving after this time we would advise a referral. In particular where the child is

aware of their fluency difficulty we would advise immediate referral.

School Years: Schools should refer via the iSEND front door (see page 14 for links).

Speech and Language Therapy Guidance Details


https://czone.eastsussex.gov.uk/inclusion-and-send/front-door-referrals/




Selective Mutism


Selective mutism is more than shyness alone; children who have selective mutism will talk freely in some situations, e.g. at home, but will have

strict rules about where they talk and who they talk with. For example, they may stop talking at home if someone outside the immediate family

unit joins them. The inability to speak interferes with children’s ability to function in that setting, and is not better explained by another

behavioural, mental or communication disorder. We would always advise referral where selective mutism is a concern; outcomes are much

better with early intervention.

School Years: Schools should refer via the iSEND front door (see page 14 for links).

Eating and Drinking

Referrals from birth

Consider referral when you see the following:

Baby has difficulty establishing or maintaining a sucking action. Any coughing, choking, colour change or nasal regurgitation

Baby is distressed when feeding or straight afterwards, they may also vomit a lot, draw legs up in pain, unable to suck on a teat, weight

loss, speak to G.P, then refer

Child unable to chew a range of textures or manage family meals, may become distressed, cough, choke at mealtimes or vomit, weight

loss

Eating and drinking difficulties as a result of degenerative condition

It is important to consider that children may present with behavioural feeding difficulties such as gagging on specific textures, rigidity

around times of eating, aversive behaviours around temperature of foods, colour of foods, texture of food and smell of food. Referrals

for children who only have behavioural difficulties in relation to eating and drinking would not usually be accepted.

If you are unsure about whether to refer, please contact the service for further telephone advice.



Speech sound delay/ disorder

Referrals from 3 years

Early Years: Referrers should use the CITES referral form (Nov 16 version). Children with significant speech sound delay/ disorder aged between 2 and 3 years will usually present with a significant language delay and any referral would be accepted on this basis (see below). By the time a child reaches their third birthday they should be mostly intelligible to most adults although they will still have several speech immaturities. If a child is still very difficult to understand after the age of 3, a referral should be considered.

School Years: Schools should refer via the iSEND front door (see page 14 for links). Please append a term’s evidence using the additional needs one page plan (assess, plan, do, review).

Language and communication needs/ developmental language disorder


Early Years: Referrers should use the CITES referral form (Nov 16 version). Parents/ carers of children under the age of 27 months are able to access advice and support through universal services and Early Communication Support Workers who work in local children’s centres.

For children over 27 months where a language or communication is not progressing in line with developmental norms a referral should be considered. Nursery settings should consider using the East Sussex Speech, Language and Communication Monitoring Tool to evidence a significant communication difficulty.

School Years: Schools should refer via the iSEND front door (see page 14 for links). Please append a term’s evidence using the additional needs one page plan (assess, plan, do, review). Referrals for language and communication needs are now supported through a joint pathway between CITES and CLASS. CLASS will provide universal support and targeted support for language and communication as needed. Cases will be passed to CITES as part of a package of support where this is appropriate.

As well as working on the development of understanding and spoken language SLTs will also advise on alternative and augmentative communication (AAC) using signs and symbols where needed.

Voice




Children with voice problems are usually referred through ENT or other specialist tertiary centre. If there are concerns about a child’s voice

quality (e.g. hoarseness, voice loss etc.) this should be investigated via ENT services first. If you are unsure about whether to refer, please

contact the service for advice.

Cleft palate


Children with cleft palate sometimes experience feeding or speech sound problems. They are usually referred by tertiary services but can be referred directly (please see under speech sound delay/ disorder and eating and drinking difficulties).

Hearing Impairment


Children with hearing impairment are usually referred through Audiology or ENT or other specialist tertiary centres. If you think a referral may be needed, please contact the service for advice.

Severe developmental delay and neuro developmental disorders


Early Years: A referral should be considered for early years children with severe developmental delay however we would prefer that referrers don’t simultaneously refer to both iSEND Early Years and CITES as this causes duplication. You are welcome to contact CITES or iSEND Early Years by phone to discuss further if you are unsure. If a child is already known to iSEND Early Years please discuss with your Early Years practitioner before referring.

School Years: For pupils in special schools, the teacher or parent should discuss with any CITES colleague who regularly goes into the school. They will be able to arrange for a CITES SLT to discuss or review the pupil’s speech and language needs. For pupils in mainstream schools, please see under language and communication needs/ developmental language disorder above for how to refer.



Downs syndrome


All babies with Downs Syndrome are referred by their Health Visitor at approximately 6 months for a speech and language advisory session. Children will receive a further advisory session in their pre-school year to ensure a smooth transition into school. If a child has speech, language and communication needs or eating and drinking difficulties they can be referred at any other time on the basis of these needs.

Autism spectrum condition (ASC)

Referrals generally from 27 months after the integrated health review but will be accepted earlier where there are profound communication needs

SLTs work with Paediatricians as part of the multi-disciplinary assessment pathway (via Paediatrician referral). Please see under language and communication needs/ developmental language disorder for further information about how we work with children with ASC and how to refer.


Referrals considered from birth

Referral for children with an acquired brain injury is always through specialist tertiary centres.

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