Pediatric PT Settings

What is the average stay in the NICU?

13 days

Level ______ perinatal care: provides neonatal resuscitation at every delivery.

- evaluates and provides postnatal care to stable term newborns

- stabilizes and provides care for infants born 35-37 weeks gestation that are stable

- stabilizes newborn infants who are ill and born <35 weeks gestation until transfer

Level I: Well-Baby Nursery

Level ______ perinatal care: provide care for infants born >32 weeks gestation and weighing >1500 g who have physiologically immaturity or who are moderately ill BUT are anticipated to resolve rapidly w/o the need for speciality services ASAP

Level II: Special Care Nursery (note: has all Level I capabilities as well)

What are other characteristics of a Level II/Special Care Nursery?

Provide care for infants convalescing after intensive care, provide mechanical ventilation for brief duration (<24 h) or CPAP or both, stabilize infants born <32 weeks gestation and weighing <1500 g until transfer

Level ______ perinatal care: provide sustained life support to infants born <32 weeks gestation and weighing <1500 g and infants born at all gestational ages and birth weights with CRITICAL illness

Level III: NICU (note: has all level II capabilities as well)

What are other characteristics of Level III/NICU?

Prompt and readily available access to full range of pediatric subspecialists, provide a full range of respiratory support that may include conventional and/or high-frequency ventilation and inhaled NO, perform advanced imaging w/ urgent interpretation

Level ______ perinatal care: located within an institution w/ the capability to provide surgical repair of complex congenital or acquired conditions while maintaining a full range of subspecialists -- can also facilitate transport and provide outreach education

Level IV: Regional NICU (note: has all level III capabilities as well)

There are ______ level II NICUs in WI

11 (ex: Bellin Hospital)

There are ______ level III NICUs in WI

16 (ex: Aurora, St. Vincent, St. Elizabeth, Children's of Wisconsin Nina)

There are ______ level IV NICUs in WI

2 (ex: American Family Children's Madison, Children's of Wisconsin MKE)

What are example of medical complications infants may have in the NICU?

Respiratory, cardiac, neurologic, and pain

______: leading cause of illness and death among pre-term infants; results from pulmonary immaturity and insufficient surfactant production (leads to alveolar collapse, decreased lung compliance, and increased pulmonary artery pressure)

Respiratory distress syndrome

What are clinical s/s of respiratory distress syndrome?

Grunting respirations, retractions, nasal flaring, cyanosis, and increased O2 requirement

______: underdevelopment of lung tissue due to very premature birth and lung injury resulting from ventilation and oxygen support

Bronchopulmonary dysplasia

______: respiratory condition diagnosed at 36 weeks of post-menstrual age; may have a continued need for supplemental oxygen or abnormal physical exams

Chronic lung disease

______: respiratory condition involving meconium stained amniotic fluid --> respiratory distress, poor lung compliance, hypoxemia, radiographic findings of hyperventilation w/ rales and rhonchi on auscultation

Meconium aspiration syndrome

______: neurological condition involves germinal matrix fragility in LBW infants; risk factors include vaginal delivery, low Apgar scores, respiratory distress syndrome, pneumothorax, and mechanical ventilation

Intraventricular hemorrhage

What are clinical s/s of intraventricular hemorrhage?

Long-term effects like neurosensory impairment, deafness, and CP

______: LEADING KNOWN CAUSE OF CP (associated w/ cognitive impairment and visual disturbances; risk factors include lower gestational age and birth weight)

Periventricular leukomalacia

What causes periventricular leukomalacia?

Cascade of events --> reduction in cerebral blood flow --> impacts white matter --> motor impairments, particularly in LE & potential visual impairments

______: neurological condition diagnosed based on fetal abnormalities, acute events, characteristic s/s, metabolic acidosis, lower Apgar scores, and image

Hypoxic ischemic encephalopathy

Clinical s/s of hypoxic ischemic encephalopathy develop >72 hours after birth, primarily caused by ______

Ischemia affecting vulnerable brain regions --> cellular energy failure or cell death

What is the mortality rate w/ severe variation of hypoxic ischemic encephalopathy?

60% (often suffer long-term morbidity, including cog. impairment, spastic quadriplegia, and seizures) vs. 10% risk of death w/ moderate variation

What are s/s of pain in infants?

Increased HR, BP, respiration, and muscle tone; decreased O2; changes in skin color, crying, facial grimacing, limb withdrawal, changes in sleep pattern and behavior

How do we address pain in infants?

Reduce stimuli, swaddle, introduce non-nutritive suckling, tactile comfort, and sensorial stimulation

What are other medical complications seen in the NICU that have not already been discussed?

GERD, neonatal abstinence syndrome, necrotizing enterocolitis, retinopathy of prematurity, jaundice (hyperbilirubinanemia)

__________: process to support infants/toddlers w/ developmental delays and disabilities and support their families (embraces prevention, remediation, experiential learning, individuality, and family centeredness)

Early intervention

____________: developmental services that are provided under public supervision, are provided at no cost except where federal or state law provides for a system of payments by families, including a schedule of sliding fees, and are designed to meet the developmental needs of an infant or toddler w/ disability in any 1+ of the following areas: physical, cognitive, communication, social or emotional, or adaptive development

Individuals with Disabilities Education Act (IDEA)

The IDEA is a law that makes available ____________ to eligible children w/ disabilities throughout the nation and ensures special education and related services to those children

Free appropriate public education

Early intervention is under Part ____________ of the Individuals with Disabilities Education Act (IDEA) of 1997 and Individuals with Disabilities Education Improvement Act (IDEIA) of 2004

Part C

Under Part C of the IDEA, federal assistance is provided to states to implement early intervention services for which age group?

Birth to 3

What encompasses early intervention/ "Birth to 3" programs? (hint: 6x)

1. Mandates family-centered services in NATURAL ENVIRONMENT

2. Addresses developmental delays

3. Reduces educational costs to society

4. Maximizes potential for independent living in society

5. Enhances the capacity of families to meet the special needs of their infants/toddlers

6. Enhances the capacity of state/local agencies/service providers to ID, eval, and meet the needs of all children

In Wisconsin, to be eligible for early intervention services, a child much has at least a ____________% delay (physical, cognitive, communication, social or emotional, and/or adaptive)

25%

Services: Early Intervention!! (hint: 14x)

1. Family training, counseling, home visits

2. Special instruction

3. SLP and audiology services and ASL and cued language services

4. OT

5. PT

6. Psychological services

7. Service coordination

8. Medical services for diagnostic or eval purposes

9. Early ID, screening, and assessment services

10. Health services necessary to enable the infant/toddler to benefit from the other services

11. Social work

12. Vision services

13. AT devices and services

14. Transportation and related costs necessary to receive early intervention

What are key elements of family-centered care in early intervention? (hint: 6x)

1. Listening to and respecting each child and family (honor diversity & include preferences)

2. Having flexible organization system

3. Sharing complete and honest info

4. Ensuring formal and informal support to child and family

5. Promoting family-professional collaboration

6. Appreciating and fostering strengths and building family capacity

What are factors that impact the effectiveness of family-centered care? (hint: 12x)

1. Knowledge of child development

2. Perception of child's behavior

3. Participation in intervention programs

4. Satisfaction

5. Developmental appropriateness of the home environment

6. Parenting behaviors and competence

7. Parent-child relationship

8. Enjoyment of parenting

9. Family functioning

10. Self-efficacy

11. Sense of control

12. Empowerment

In early interventions, outcomes for children are mediated by ____________, while outcomes for families are mediated by ____________

Children = parent self-efficacy and parent-child interactions

Families = parent self-efficacy (key mediator of family-centered care)

What does family engagement refer to exactly in terms of family-centered care?

Active investment and involvement (essentially, engagement reflects a family's receptiveness and commitment to the process and their confidence when participating in the intervention)

What are the three dimensions of engagement?

1. Affective (emotional involvement -- hopeful attitude & trust in the process)

2. Cognitive (commitment to the goals and belief in the relevance of the intervention, willingness to invest time and effort)

3. Behavioral investment (confidence in being able and supported to participate)

Reflections: engaging families in early intervention services

Parent may not understand or have different perspective regarding family involvement, parent may need respite (time alone or to accomplish a task)

Considerations: engaging families in early intervention services

Share philosophies, discuss ways to be involved, ask what they would like to focus on, share how we can provide support, be patient + share highlights of the session + find moments to connect w/ the family, incorporate watching TV and chores, agree on a balance, discuss family's interest in or need for respite resources

Early Intervention leads to increased ____________, and families report being competent in caring for their children's basic needs (i.e., know their rights, effectively communicate their children's needs, and help their children develop and learn)

Motor, social, and cognitive functioning (in fact, many children achieve greater than expected growth and exit early intervention functioning within age expectations)

What is the role of PT in early intervention? (hint: 3x)

1. Acquisition of motor skills

2. Promotion of children's activity and participation (motor learning, environmental adaptations, AT, family support and education)

3. Health promotion and prevention (discerning risk factors for secondary issues, fostering safety, ID s/s for the need for referral)

What is "coaching" in early intervention?

Advocating for family involvement in the intervention process and respecting the family's strengths and expertise, supporting them in expanding their current abilities and learning new skills WITHIN THEIR NATURAL ENVIRONMENT

What are some barriers to effective collaboration b/w medical and early intervention providers?

Lack of communication, lack of trust and understanding, challenges of difference in practice philosophies

____________ approach: multiple team members from various areas of expertise work together towards one set of outcomes

Interdisciplinary approach

____________ approach: one primary service provider implements the IFSP w/ consultation from other team members

Transdisciplinary approach (note: the family has access to the other team members as needed, but this approach is dependent on sharing roles and crossing disciplinary boundaries)

Steps to early intervention: describe the family interview (what is it? purpose?)

An initial step in the eval & assessment process to learn about the child's health, personality, daily routines, family concerns

*MAKE SURE TO USE ACTIVE LISTENING*

Steps to early intervention: how should a child be observed?

Within their natural environment!! (family household routines, parent-child interaction, play, and other daily activities)

Steps to early intervention: _________ is a document used to guide early intervention service delivery

Individualized Family Service Plan (IFSP) (note: remember that this document is always family-focused!!)

Who are the team members of the IFSP? How should it be developed?

Parents, caregivers, other family members, the family advocate, the service coordinator, providers involved with the eval & assessment, and providers who will be providing the service

Must be developed in a timely manner at a meeting time & place that is convenient for the family

How often is the IFSP reviewed?

Every 6 months or more, often at the request of a team member, w/ a formal meeting held annually (allows for revisions, monitoring, and renegotiations)

What encompasses the IFSP? (hint: 9x)

1. Present levels of development (cognitive, communication, physical, social or emotional, adaptive)

2. Family's resources, priorities, and concerns

3. Measurable outcomes expected w/ criteria, procedures, and timelines of progress

4. Specific early intervention services w/ FITT-VP principles

5. Natural environments in which services are to be provided (or justification as to why it won't be)

6. Other services to enhance the child's development and a plan to secure them

7. Projected dates for the initiation of services and duration

8. ID of the service coordinator

9. Transition plan

What is considered the "natural environment"?

Settings that are natural or normal for the child's age peers who have no disabilities (i.e., "a variety of settings where children live, learn, and play," including people and relationships, routines, and activities)

True or false: activities that were appropriate to daily routines had the strongest relationship w/ adherence

TRUE!!

Intervention strategies: team collab

Schedule team meetings, conduct covisits, ID and access community resources, establish interagency coordination, visit or phone-conference, share documentation

Intervention strategies: natural environments

1. Provide info & resources on family-ID concerns

2. Embed intervention strategies into daily life

3. Conduct visits when family members can participate

4. Conduct visits at community locations

5. Provide interventions in different rooms w/ a variety of activities and routines

6. Use the coaching process, use family materials and toys

7. Implement adaptations + functional training + restorative/preventative techniques to support self-regulation + adaptive behavior + parent-child interactions + self-care + mobility and play + sibling/peer interactions

When a child transitions into the school system, Part C --> __________ and IFSP --> __________

Part C --> Part B (Preschool Services)

IFSP --> Individualized Education Program (IEP)

Summary: early intervention utilizes the __________ environment w/ a __________ method to enable parents to work w/ their children to gain different skills

Natural & coaching

Federal legislation mandates the provision of PT for students w/ disabilities who require those services to enable them to __________

Benefit from their special education program

__________: component of the Education for All Handicapped Children Act that requires free public education for ALL children 6-21 (or 5 years if the state provided this to non-disabled children)

Free and Appropriate Public Education (FAPE)

__________: component of the Education for All Handicapped Children Act that ensures ALL children receive an education

Zero Reject

__________: component of the Education for All Handicapped Children Act that promotes the max. extent appropriate that children w/ disabilities are educated w/ children who are NOT disabled -- special classes, schooling, or other removals from the education environment ONLY occurs when the nature or severity of the disability is such that education in regular classes cannot be achieved satisfactorily

Least Restrictive Environment (LRE)

__________: component of the Education for All Handicapped Children Act that involves a right to an impartial hearing, representation by counsel, verbatim transcript of written findings, and appeal for an independent eval

Right to Due Process

__________: component of the Education for All Handicapped Children Act stating that no one test should ever be the sole criterion for eligibility

Nondiscriminatory evaluation

__________: component of the Education for All Handicapped Children Act; required for every child receiving special education in the school setting (Part B of the IDEA); outlines the specific education, related services, and supports the child is to receive and includes measurable goals

Individualized Education Program (IEP)

What does it mean that PT falls under a "Related Service"?

PT may help the child explore their environment, perform ADLs, improve function in school, prepare for vocational training, and improve physical fitness to be better prepared to learn and participate BUT it cannot be a stand-alone service

Children are considered eligible for special education & related services if they have 1+ of the following: __________

Intellectual impairment, hearing or speech/language impairment, visual impairment, orthopedic impairment, autism, TBI, etc., or specific learning disabilities who by reason thereof needs special education and related services at the discretion of the state

Children w/ a disability might include those experiencing developmental delays at 3-9 years, with __________ areas required to qualify

2/5 areas

__________ is the MOST updated reauthorization of Education for All Handicapped Children Act

Individuals with Disabilities Education Improvement Act of 2004

Part __________: recognition that education encompasses MORE than traditional academics; intended to prepare children for independent living and self-sufficiency

Part A

Part __________: outlines the right for all children 3-21 years of age to a free, appropriate public education that emphasizes special education and related services to meet their unique needs and prepare them for further education, employment, and independent living

Part B

__________: any item, piece of equipment, or product system used to increase, maintain, or improve the functional capabilities of a child w/ a disability

Assistive technology (AT_

__________: any service that directly assists a child w/ a disability in the selection, acquisition, or use of an AT device

AT service

__________: program that focuses on children from Kindergarten to 3rd grade, who would benefit from additional academic services and behavioral support to succeed in the general education environment

Early Intervening Services (EIS)

__________: program that involves high quality instruction intervention, using the student's learning rate and level of performance for decision-making

Response to Intervention (RIT)

__________: antidiscimination statute to ensure that federal-funding recipient provide equal opportunity for people w/ disabilities

Section 504 of the Rehabilitation Act (used to expand a student's eligibility)

Under Section 504, you are NOT allowed to exclude __________ from participation in any program offered by the agency

Qualified individuals w/ disabilities

__________: any person who has a physical or mental impairment which substantially limits major life events, has a record of such an impairment, or is regarded as having such an impairment

Handicapped person

What are examples of major life activities?

Caring for oneself, performing manual tasks, walking, seeing, breathing, speaking, hearing, learning, and working

True or false: a child who does not require special education may be able to receive all of the aids, services, and accommodations necessary to receive a free and public education through Section 504

TRUE!! (ex: a girl w/ a prosthetic leg may need a WC if her prosthetic falls off, and even though she doesn't qualify for an IEP, she would qualify for a 504 Plan)

The ADA "extends to individuals w/ disabilities comprehensive civil rights protection similar to those provided to persons on the basis of race, sex, national origin, and religion under the Civil Rights Act of 1964"...what does this mean?

Regulations carryover into employment, public services, public buildings, and public transportation

__________: act that emphasizes equal access to education for all children and encourages high standards and accountability; provides federal funding for education programs that are admin. by the states

Elementary and Secondary Education Acts (ESEA)

What is an "Extended School Year (ESY)"?

In the case that a child shows sig. regression of skills following breaks, an ESY is incorporated into their IEDP (ex: offering summer school to make sure that they don't regress and take an extended amount of time to recoup their benefits in the fall)

What criteria qualifies a person for ESY?

Individual need, nature and severity of disability, educational benefit, regression, recruitment, self-sufficiency, independence, failure to meet short-term goals

__________ education: language has changed from mainstreaming --> integrated --> __________; allowing equitable participation in the school community

Inclusive Education

__________ (model of team interaction): members of the same profession work together w/o sig. communication w/ members of other professions

Intradisciplinary

__________ (model of team interaction): discipline-specific roles are well-defined and professionals work independently BUT recognize and value the contributions of other disciplines. May be little interaction. However, also defined as "the involvement of 2+ disciplines or professions in the provision of integrated and coordinated services, including eval and assessment."

Multidisciplinary

__________ (model of team interaction): discipline-specific roles are well defined; however, individuals from different disciplines work together cooperatively on planning, implementation, and eval of services. Emphasis is on teamwork. Role definitions are relaxed.

Interdisciplinary

__________ (model of team interaction): professionals are committed to working across disciplines and sharing info. Role release occurs when a team member assumes the responsibilities of other disciplines for service delivery.

Transdisciplinary

__________ (model of service delivery): work directly w/ the child; may be in a separate environment; emphasis on the acquisition of motor skills when there's therapeutic techniques that CANNOT be safely delegated to other staff members

Direct (most common model in traditional PT)

What is an example of direct service?

Skill necessary to help a child learn how to walk is more than a parapro can bring to the table --> PT works directly w/ the child

Therapist's primary contact: direct service

Student

Environment: direct service

Distraction-free; specialized equipment needed

Methods of intervention: direct service

Educationally-related functional activities, specific therapeutic techniques that cannot safely be delegated, emphasis on acquisition of new motor skills

Amount of actual service times: direct service

Regularly scheduled session -- at least weekly

Implementer: direct service

PT, PTA

__________ (model of service delivery): team collaboration and in learning/natural settings; services are provided in the classroom vs. pulling the child out to the PT gym

Integrated -- includes direct AND consultative PT serves

What is an example of integrated service?

A child working on standing skills with a stander is able to have the parapros set him up on days the PT is not there

Therapist's primary contact: integrated service

Student, teacher, parent, aide