AOTA Pediatrics

What age is a ped?

0-21 years

Age in Months

Infants

toddlers

infants 0-12

toddlers 12-36

Age in years

Pre-k

elementary school

middle school

high school

pre-k 3-5

Elem 6-10

middle school 11-13

high school 14-18 /developmental delays 21

General principles of development?

Dominance of flexion to increased extension

Security in prone to supine

Movement of the center of gravity from the UB to the pelvis frees up the UB for fxnl tasks

increased dissociation during movement

lateral mvmts to midline

ability to move against gravity

increased stability and freedom of movement for fxnl tasks

Piaget theory of development

• showed children think in different ways than adults

• Cognitive development is a reorganization of mental processes rather as a result of nature and nurture

• Schemas are the basic building blocks of intelligent behavior

Sensorimotor	Preoperational	Concrete operational	Formal Operational
0-2	2-7	7-12	12 and up
Understands the world through senses and actions Simple problems are solved using movement and sensation Retrieving a hidden toy	Understands the world language and mental images Does not yet understand conversation or reversibility Large objects swims in water	Understands the world through logical thinking and categories Understands concepts of conversation and reversibility Adding and Subtracting beads	Understands world through hypothetical thinking and reasoning Able to predict consequences, able to test own hypothesis Defining justice

Eriksons theory of psychosocial development

• 8 psychosocial stages across the lifespan

• Each stage contains a stage-specific conflict

• Differences in personality can be explained by the way a conflict was or was not resolved 

• Thinking becoming more complex

Approximate age
Infant to 18	Trust vs mistrust
18 months – 3 years	Autonomy vs Shame & Doubt
3 – 5	Initiative vs Guilt
5 – 13	Industry vs Inferiority
13 – 21	Identity vs Role Confusion
21 – 39	Intimacy vs Isolation
40 – 65	Generativity vs Stagnation
65 and older	Ego Integrity vs Despair

What occupations do Pediatric OT’s consider?

ALL :)

IDEA parts

Key principles of IDEA

OT is provided as a related service that is:

Collaborative

LRE/inclusive

FAPE

Due process

Team tiers of OT

Tier one: high quality classroom instruction with support for all students

Tier two: targeted support for identified students in smaller groups as part of the whole classroom

tier three: intensive 1:1 groups support for short periods for students who need assistance

Chromosomal disorders

deficit in the qauntitiy of chromosomes - too many or too little

some inhertited

most spontaneous

Autosomal disorders

involve fault in one of 22 autosomes

Vocab review

• Natal

• Prenatal

• Perinatal

• Postnatal/postpartum

• Something related to birth/native

• before birth

• during birth

• after birth

Review of gestational development cycle

Germinal	Embryonic	Fetal
2 weeks from conception	3-8 weeks	9 weeks to birth
the zygote implants into the uterine walls	All major body structures formed	Complex structural changes
Circulatory system starting	Most susceptible period	Weight gain
	Development from proximodistal to cephalocaudal	28 weeks: most neonatal reflexes are developed
		32-36 weeks: sucking reflex begins

Examples of pediatric conditions related to the prenatal enviornment

Intrauterine infections

Maternal exposure to taratogenic agents

Examples of pediatric conditions related to the perinatal enviornment and events

1. Birth trauma

2. Intercranial hemorrhage

3. anoxia/asphyxia

Examples of pediatric conditions related to Postnatal Events 

1. Trauma

2. Disease

ADHD overview

Boys go jupiter /more likely

impulsive/hyperactive/distractible/combined

Brain activity decreased in Parietal lobes (inhibition and attention)

meds + additional intervertion required

ASD overview

Neurobehavioral disorder

onset before 3 YO

More likely in Boys

Challenges with:

Communciation, prosody, pragmatics, popularity(social skills), sensory Processing, repetive behaviors

Often have dyspraxia or poor motor planning abilites

Behavior issues overveiw

May be refinforced by accident

occurs in patterns

May be caused from:

• Maturation

• Temperament

• environment

• lack of experience/information

• unmet emo needs

• to obtain something

• to avoid/escape something

Behavioral disorders overview

less systematic and cannot be extinguished by changing consequences

often require psych assistance

Developmental trauma overveiw

decribes trauma that has happened in early life during critical development periods - can have impact on the brain

Risks for hearing impairment

• Prematurity and neonatal intensive care unit stays

• delayed speech and language skills

• in utero infections

• craniofacial anomalies

• syndromes associated w/hearing loss

• postnatal infections

• head trauma

  • chemotherapy

Hearing impairment Peds Team members

SLP

Audiologist

Educational personnel

Children with developmental disorders are also likely to have what additonal impairments?

Visual

Common visal conditions

cortical visual impairment

retinopathy of prematurity

microphthalmia

anopthalmia

childhood glaucoma

retinoblastoma

congential cataracts

Examples of common postural and motor presentations in children with visual impairments

Hypotonia

shoulder and pelvic instability

pronounced head tilt to one side

Hyperextended neck

wide BOS

tendency to move in straight planes

high gaurd posture when walking

Visual impairment phsycial red flags

eye shake

execessive large or small pupils

eyes not in alignment

pupils not black or that appear to have opaque film

Behavioral impairment phsycial red flags

moves closer to objects or surfaces that need visual attention

squinting, staining, rubbing eyes, closing one eye, excessive head mvmts

headaches

avoidance of work tasks

Performance impairment phsycial red flags

Appearing clumsy

difficulty locating needed items

trouble learning alphabet and recognizing spatial concepts

difficulty writing, drawing, reading

social difficulty

lack of interest

Intellectual disabiltiy overview

indicated with measured with a psychoeduactonal assessment - with score more than 2 SD below norm range for their age

indentified before 18

impairment of adaptive abilites that are necessary for ADL’s and IADL’s

Levels of ID

mild: IQ btw 55 and 70; learn skills at 3-7th grade level, Min-A

Moderate: IQ 40-55, 2nd grade level, able to perform some skilled tasks

Severe: IQ 25-40L able to communicate and perform basic ADL’s, requires support to complete routines

Profound: IQ below 25; requires Max-A from caregiver; often coupled with additonal deficits

Causes of ID

Aquired in childhood through trauma, toxins, or infection

problems during development and birth

chromosomal disorders

CNS malformations

Cogential anomalies

Metabolic, neurocutaneous, and endocrine disoders

Common ID comorbities

Speech deficits

ambulation problems

seizures

visual defcits

chronic health conditons

Early indicators of ID

Delays in meeting motor and slp milestones

unresponsiveness to handeling and physical contact

reduced alterness

limited reactions to play

feeding difficulties

neurological soft signs - aka poor balance, motor asymmery, decerased GMC/FMC

When is a formal dx made for children with an ID?

When the child enters school because of the emphasis on performance on psychoeducational assessments.

Learning disabilites overview

a group of problems that affect a child’s ability to perform and master academic skills, process information, and communicate effectively.

not assocaited with neurolgoical insults

Common types of learning disabilites

Dyslexia

Dysghrapia

Dyscalcula

5% - 11% of school age children have what type of disorder?

Mental health

Anxiety overview

Pervasive sense of worry, fear, and apprehension

impact on perf skills and client factors include:

energy

time mgmt

ogranizing space and objects

adapting performance

social interaciton skills

digestive system functions

mental functions

Depression

• Required dx of at least 5 different symptoms

• Dx is made in absense of bodily causes

• Occurs d/t psychosocal stressors, genetics, sensory changes, and CNS changes

• High prevalence in 12+ YOs

• Clients generally able to return to Indep occupational functioning

Depression impacts on function

• School and social fx’s

• Inability to participate in leisure, ADL, & IADL activities

• Cognitive impact: loss of concentration, diminished problem-solving ability, poor coping

• Slowed or increased psychomotor activity

BPD overview

Fluctuations in mood w/alternating episodes of mania and depression

Type 1: intermittent manic and major depressive episodes

Type 2: Intermittent hypomanic and major depressive epiosdes with no occurence of manic episodes

Cyclothmia: Marked mood swings between depression and elation

BDP cause

• Genetic influence clear familial pattern

• Prevalence among younth - particulary in adolesence

• chronic with high reoccurence rate

BPD Impacts on function

• Suicidal thinking or behaviors that affect social relationships

• Intense emotional states that affect performance in school

• Episodes of drastic changes in mood and behaviors that affect relationships with others

ODD overview

A pattern of negativisitic, hostole, and defiant behavior lasting at least 6 months

• causes clinically significant impairment in social, academic, or occupational functioning

• typically dx’d in preadolesence

Anorexia

intense fear of gaining weight; unrealistic body image

• Usually marked by severly restricting caloric intake and/or execessively exercising to lose weight

  • caused by combo of psychologic, social, and physiologic factors

Bulimia

Characterized by excessive secretive eating followed by inappropriate methods of weight control

• unrealistic body image

Impacts of childhood eating disorders on perf skills and client factors

• strength

• energy

• time mgmt

• adapting performance

• mental fxs

• cardiovascular fxs

• neuromusculoskeletal functions

  • digestive functions

Cerebral Palsy Overview

CP is a nonprogressive condtion that encompasses neurolgocial, motor, and postural defecits

• common fxnl comorbs include: lang, cog, sensory, and psychological deficts; seizure disorders; and feeding impairments

Congential CP

• Prematurity* d/t increased sensitivity of the CNS before full term birth

• Infants born btw 26-32

• Cerebrovascular accident at or around time of birth

• maternal exposure to enviornmental toxins may also cause congential CP

Aquired CP etiology

• May result from:

  • Trauma

  • Intercranial hemorrhage

  • CNS infections

  • Near drowning

  • Hypoxia

  • Metabolic disoders

How is CP dx?

Evaluations take place over several months and include physicians. physical therapists, and SLP

The following key markers of CP may be noted during the evaluation:

• Retention of primitive reflexes and automatic reactions

• Abnormal or varialbe muscle tone

• Hyperresponsiveness tendon reflexes

• Asymmetrical use of extremities

• Clonus

• Poor feeding and tounge control

• Involuntary movements

Which types of CP are characterized by dofficulty maintaining typical muscle postures bc of a lack of muscle coactivation and by the development of compensatory movement patterns?

Both congential and aquired CP

Classification of CP is based on what factors?

• Limb involvement

  • Diplegia

  • Quadriplegia, tetraplegia

  • hemiplegia

• Distribution of tone

• Quality of tone and function

  • Spasticity

  • Athetosis

  • Choreoathetosis

  • Flaccidity

  • Ataxia

• Fxnl classification or based on how the child can participate in and interact w/the enviornement

Visual comorbs commonly occuring with CP

• Strabismus

• Nystagmus

• Dysarthria

• Aphasia

Muscular dystrophies overveiw

MD results in progressive degeneration and weakness of a variety of muscle groups and could lead to death

• degeneration is a result of biomechanical and structural changes of the surface and internal membanes of the muscle cells

• hereditary links

• ex:

  • Limb girdle dystrophy

  • Facioscaupulaohumeral MD

  • Duchenne’s MD

  • Congential MD

Limb Girdle Muscular Dystrophy

Affects the proximal muscles of the pelvis and shoulder girdle

• Onset occurs within the first 30 years of life

• progression slow

Facioscapulohumeral MD

Affects the face, UE’s, and scapular region

• Onset usually in adolescence

• This type of dystrophy is characertized by the sloped shoulders and limited ability to raise the arms above the head

• Decreased mobility in the facial muscles results in a “masklike” appearance

Duchenne’s MD

The most common form of MD affecting only boys

• Caused by a deficiency in the production of dystrophin; muscles degenerate w/o dystrophin

• Boys with DMD develop typically after birth and begin to demo symptoms btw ages 2 and 6

• Enlarged muscles and postive sign for Gower’s present

• progresses quickly - children often need to use w/c by age 9

• ADLs become increasingly difficult

• typically die in their 20’s d/t respiratory/ ❤ problems

Congenital MD Overview:

& types

A heterogenous group of disordres with onset in utero or during the first year of life

• brain involvement is apparent, along w/neuromuscular dysfunction

• Characterized by hypotonia, generalized muscle weakness, and contractures

• common comorbs include:

  • Clubfoot

  • torticollos

  • diaphragmatic involvement, and congenital heart/spinal defects

Four types

CMD 1: Does not include sever intellectual functioning difficulties

CMD 2: Involves muscle and brain abnormalities

CMD 3 & 4: Involves muscle, brain, and eye abnormalities

DX confirmed by the presnece of high serum levels of creatine kinases by imaging and biopsy

Neural Tube Defects

Malformations that occur in fetal development

• The rate of neural tube defects is decreasing possible bc of increased awareness of the importance of folic acid for women in their child-bearing years

Three major forms of neural tube defects:

Encephalocele

• a protrusion in the occipital region of the brain

• typically associated w/severe deficits, such as cognitive impairments, hydrocephalus, motor impairments, and seizures

Anencephaly

• Neural development above the level of the brain stem i slacking

• do not survive infancy

Spina Bifida

• most common type

• congenital defct of the vertebral arches and spinal column

• can be identified through amenio

Spina Bifida Occulta

Mild form - no symptoms may be present and only consists of 1 or 2 affected vertebrae and non involvement of the spinal cord

Meningocele Spina Bifida

involves an extensive spinal opening with an exposed pouch of cerebrospinal fluid and meninges

Myelomeningocele

Most servere form: in addition to an extensive spinal opening with an exposed pouch of cerebrospinal fluid and menges, the nerve foots are also exposed.

• children with this usually display sensorimotor problems at or below the level of the legion

• LE paralysis and loss of sensation is common

• Some children w/also have hip, spinal, or foot deformities

• complications include hydrocephalus and Arnold-chiari syndrome

ASI

Proximal sesnes are emphasized

• Vestibular

• Tatctile

• Propropceptive

Senses are thought to dominate a child’s early life experiences

Distal senses are not thought to have a large impact

• vision

• hearing

Sensory processing

Ability to take in information through our sensus, organize and interpret information and then have an appropriate response

• children w/challenges w/snesory processing may have a clinical dx of sensory processing disorder. They have extreme responses to sensory input; can be hypo or hyper responisve

Sensory processing disorders: Neurologic concerns

• Optimal brain function is based on sensory input

• A lack of sensory input at critcal points in development may result in learning or behavioral disoders

• for sensory input to be effective it must be matched to the childs specfic CNS requirements

  • The child must be able to organize and use sensory input to respond to the enviornment

  • Adaptive response: children w/typical CNS will seek out sensory input they need to help ogranize themselves to achieve their goals

  • Plasticity: the ability of a structure an cocomittant function to be changed gradually by its own ongoing activity.

  • Ayers:

    • Vestibular input - processed in the brainstem

    • Somatosensory input - processed in the thalamus

Sensory intregrative problems: overview of modulation deficts

• Sensory Modulation is regulated by the CNS of its own activity.

• Problems with modulation are characterized by children being unable to grade their responses to external stimuli

  • Over/under responsiveness

• Sensory Seeking thought o be d/t hyposenstivity

Children seeking vestibular input may be thought to be?

Risk takers or reckless

Children seeking proprioceptive inout may be thought to be?

Trying to meet thier needs by engaging in roughhousing and other activities that provide them w/deep -pressure input or muscle resistance. Children who seek this input may be trying to regulate their experiences of touch or movement

Overesponiveness to stimuli may be d/t the result of tactile defensiveness or gravitational insecurity

Tactile defensiveness: is an extreme overreaction to tactile input; light touch may be particular noxious. Children may be sensitve on their face, abdomen, or palmar surfaces of hand

Gravitation insecuritiy: is overresponsivity to vestibular input; children with this type of dysfunction may be extremely afraid of movement and may move carefully.

Overresposivity: may be present in any of the other senses as well

Sensory discrimination and proprioceptive probems

Tactile discrimination

• FMC skills may be delayed

• being able to feel objects and use them efficiently

• Children may have difficulty with visual motor tasks and motor planning in general

• must be taught to compensate for motor skills by using visual guidance

Difficulty with proprioception is characterized by appearing?

gwaky and awk w/difficulty grading force

• may struggle to get the info they need from their muscles and joints

• cog strats can be used to help them compensate

Visual perceptual problems are common in children with other SI dysfunction may have difficulty with?

form, space perception, figure-ground perception, and spatial orientation, depth perception and visual closure,

Vestibular proprioception probelms are characterized by?

Poor bilateral coordination and sequencing of actions

• Projected action sequences: motor planning in relation to enviornmental changes are difficult

• common presentations include: decresed equilibrium reactions, poor posutre, lower than average tone, and dleyaed GMC skills

Dyspraxia

involves difficulty with any of the 3 parts of praxis i.e ideation, planning, and execution.

PEOP intervention considerations

• Family cenetered approach

• consider context of family and community/Env

EHP assessment and interevention considerations

Eco of human perf:

• Persons is composed of their pefromance skills within the task

• the task determines specific behaviors for success

context includes time, social, and envionrment aspects

Intervention:

• Create promte

• Establish restore

• Alter

• Modify

• Prevent

Assessment:

• Identify what the childs wants and needs are

• eval contextual features

• identify childs perf feats

• analyze characteristics of desired tasks

• develop hypoth and associated intvns

MOHO assessment and intvn

Intrervention

• occupational participation - perf in daily routines

• occ perf: increase ability to engage in occupations

• occ skills: demo improved actioons associated w/occs

Assessment:

• *short child OP (determine if volition, habit, and env faciliate or restrict occ participation

• Child Occ self-assess (covers ADLs and self satisfaction)

• pediatric interest profiles (play and leisure interests)

• pediatric volitional questionaire

• school setting interveiw

Occupational Adaptation model

Person

occ envionrment

interaction of person and enviornment

assessment:

• understand person, envionrment, and desired outcome

Intervetion

• occ readiness: improvements in FMC/GMC etc

• occ act: addressing core fts of childs of familys difficulty engaging in desired occs

Aquistional FOR and intervention

learning is influenced by the interaction btw a person and their interaction in the envionrment - a skill can be taught or learned within context of the env and fxnl behaviors

Intvn:

• teach discrete skills

Bevahoral FOR and intervention

uses behavorial techs to bring about behavior change and build perf skills

intvn:

• use of shaping, chaining, extinction of, reheresing specfic behaviors

• a stimulus evokes a learned response and this can be learned through reinforment

Biomechanical FOR and intvn

Used with neuro or musculskeletla dysfunctions and cannot maintain muscle activity or posture - AE may be used to help compensate for lack of function

intvn:

restoration of muscle, positioning for fxn, provision of AE, splints, furniture, devices

Cog-Behav FOR and intvns

use of client centered goal setting. Psychoeducational groups, use of problem solving, application of knowledge in skill building, or improve the ability to problem solve

intvns

• use of client centered goal setting

• psycheducational groups

  • use of problem solving strategies, self mgmt, hw, and mindfullness meditation may be used.

CO-OP

People are taught to use metacog strats to overcome deficits including related to executive functioning. Clients learn to create their own strategies to improve functioning

intrvns

• coaching client through process of anaylzing thier own behavior and outcomes

• brainstorming strategies that could be used to address deficits

• implement strats and eval functioning

NDT FOR and interventions

ndt approach to facilitate normal developmental patterns of movement

intrvns

• restoration of functional movement by act calling for certain patterns of mvmt or posture

Task oriented approach / function based approach

uses client centered goals and engages cleint in solving motor problems through everyday tasks, selected and graded to promote motor learning

• everyday tasks

• practice schedules

Psychosocal FOR

promote aquiring social skills, social participation, and mental health w/a focus on fxnl social behavior

Rehabilitation FOR

Adaptive or compensatory apporaches to maximize function in daily activities despite lasting impairments

Sensory intergration and processing

Integration: promotes combo of sensory input from diff sensory systems to develop an adaptive response

processing: addressed failure to organize input coming from multiple sensory systems such as proprioception, vision, auditory, tactile etc. to adeq func.

• hyper, hypo, mixed response, sensory seeking/avoiding

intvn:

• guided provision of sensory stimulation and goal-directed meaningful play such as activities and games suspended equiptment or requiring large inputs of tactile or prop stimulation

Autism eval & intervention general considerations

• Observations often sub for formal eval

• an integreated development model is used when conducting assessements

• Organizational skills along w/other execitive functions, should be explored during the OT Eval

• Many people with mild ASD may experience sensory processing disorders and should be a focus of the OT assessment

Autism Assessment strategies

• Record review: examine signficant information and medical records

• Skilled observation: Preferred over long standardized tests; note variables that affect partcipation and performance (at home, school, and community)

• Interviews: gather information about areas of concern to parents, caregivers, children, and others

• Measures: norm-referenced, criterion-referenced tests, and ecological tests

Autism Evaluation Areas

• ADLS

• Emo reg

• family occupations

• Play

• Participation in school

• Sensory integration and praxis

• Social skills

• technology needs

Trauma

Is the result of an intensely threatening event that exceeds the ability to protects one’s phsycial and psychic well-being and integrity

Developmental Trauma

Describes trauma that has happened early in life or during critical development periods. It can have impact on brain development.

Areas of evaluation for children w/trauma

Sensory

Self-regulation

Play and peer interactions

Self-concept

Behavior

Executive function

Examples of intervention for children w/Trauma

• focus on parenting goals

• focus on family relationships

  • in schools - may require helping stakeholders understand the impact of developmental trauma on learning

Handwriting OT Process considerations

• Detemine the writing tasks that are most difficult for the child

• Track the behaviors that are evident when the child is required to write

• Determine what assistance or cueing if any the child needs to complete writing tasks

• Determine wether the child is distracted by any visual or auditory stimuli

• Consider where the child sits in the classroom

• Reveiw if the handwriting cirriculum if any being used

• Consider the location of the teacher when instruction is being given

• determine how the writing difficulty affects the childs learning

• Consider ergonomic factors, such as writing posture, upper extremity stability and mobility, and pencil grip