Peds Exam 1

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Supporting Parent Responsiveness and Child Learning- Where is your thick line? This graphic helps us understand what we are doing in birth to three- ***Relationship-based intervention is really what we strive for - As a home visitor you are really working with the parent- because they will be the direct interactors of the child - Really supporting parent and understanding what they are seeing and want to do action wise

****Parent-therapist dyad is really important b/c the parent is most able to facilitate child development b/c in most contact - Need to build trust with parent in order to make changes - Sometimes need to meet the needs of the caregiver first in order to be able to meet the needs of the child - often hard to balance this - It can be challenging work sometimes -this is why you need a team behind you - Need to remember this is what a parent wants and their needs - not about yours

Components of Pediatric Evaluation Interview observation standardized non-standardized assessments- make up a pediatric evaluation Similar to adult evaluations--but what's a BIG difference??

***But a big difference is we can do in pediatrics= observations in their NATURAL ENVIRONMENTS- schools, in the home, or in community, or even in clinic

Intervention- Facilitate co-occupational engagement ***Establish/restore Approach designed to change client variables to establish a skill or ability that has not yet developed or to restore a skill or ability that has been impaired Ex. Feeding a toddler

***Looks like the toddler is not happy to participate So as an OT- we are experts in sensory processing and motor skills May establish and restore a skill or ability that has not developed yet Could work on some of oral defensiveness The toddler is not holding the spoon so may work on fine motor skills to develop ability to hold spoon and self-feed

Developmental monitoring + screening = more kids in early intervention compared with DS or DM alone!

***The best approach is developmental monitoring and developmental screening TOGETHER is the best way to ID children early Developmental monitoring takes place over a long period of time- with parents, teachers, HCP - can be done with-is ongoing (like making a quilt) Developmental screening- usually done by a healthcare professional - Is a more formal process- if parent has a concern about LTSAE materials- then child should be screened - HCP goes through and scores different areas then go forward for further evaluation - Parents aren't always listened to so LTSAE helps HCP take their concerns seriously

***You can use non-standardized just not as accurate and lower confidence in reliability and validity

Intervention- Facilitate co-occupational engagement ***Prevent Approach designed to address the needs of clients with or without a disability who are at risk for occupational performance problems. This approach is designed to prevent the occurrence or evolution of barriers to performance in context.

**Prevention- thinking of caregiving activities that can prevent even thinking of DIAPER RASH Toddlers can let people know if their toilet needs to be changed- some babies can't perceive discomfort or pain Can use co-occupations to prevent occurrences of diaper rash

Observations in pediatric evals ¡ Provide diversity of opportunity ¡ Structuring of observations ¡ Note taking ¡ Record conditions of the environment

**Want to get as many environments as you can (school, home, clinic) - How do you structure your observations- are you seeing the child in settings that show you what the problems are --You have to talk to the people that are around the school and In the class (teacher needs to know you are coming, and you can't distract the child or class by being there) **Take lots of notes - Record conditions of environment- where are the seats, who is talking- sensory, auditory, tactile, path of classroom - The same as the home setting- structured home environments vs. disorganized homes vs. relaxed and messy vs. relaxed and organized **Just need to take notes of all of this

Scoring Tests - The Bell Curve for z-score & t-score

- Anything BELOW 2 SD of the mean or more in a t-score, z-score or standard score- automatically qualifies for OT - Anything 1 to 2 below SD may qualify for therapy - not a hard and fast rule - could make improvements on

Behavioral FOR

- Based on animal research examining learning - Learning occurs through repetition of specific behaviors with appropriate reinforcement - Use reinforcement to modify or alter behavior - Puts little emphasis on intrinsic motivation, as motivation to perform a skill is generated by external motivation provided by reinforcement - Requires careful analysis to determine what to reinforce and when Can see this in token economies Kid may receive positive reinforcement- ex. Go to a school store and purchase something May make it harder for child to generalize behavior to other environments/situations

Why co-occupation? Because of what science tell us......

- Because in early childhood co-occupation is a necessity for survival and the quality of the co-occupational experience shapes the structure and function of the developing brain Science tells us we need to focus on early childhood If a baby isn't fed, the baby won't survive or if it's not bathed it won't have optimal outcomes So we really need to focus on co-occupation at this time!!!

Children receiving birth to three services don't automatically qualify for early childhood services

- Birth to three (family-driven) is completely different than early childhood (child educational attainment is focus)- the system drives much more what children are eligible for Birth to 3 do collaborate with early childhood b/c transitions are hard especially for children with disabilities - This helps to make transition easier

- If we are just being child-centered in our interventions at this time, we are missing an opportunity at this time for mothers to interact with their babies - When moms are experiencing depression or PTSD and they receive treatment by Ots- outcomes for both MOM and BABY improve!!! We as OTs need to pay attention to the DYAD

- Brain development is dependent on habits and routines- depends on mothers nurturing

PCATT used in birth to 3 in Wisconsin IDEA= federal law - States birth to 3 need to be provided with an EBP model PCATT is an example of a EBP model

- Family centered - A multidisciplinary team but select a primary service provider who uses coaching as a form of intervention to build capacity of parents - This is different than a lot of models - think of the Verizon commercial- have an entire team behind you but one person is the head of the team

Structure of birth to three- natural environment through every step in birth to three process Step 4. IFSP Development- match outcomes and intervention strategies to the families priorities, needs and interests, building on routines and activities they want and need to do

- IFSP Development- if child- IFSP (individual family service plan) the contract you have with the family of the goal you are working toward and the services you are providing

2005 study- mothers who experienced depression interact w/babies in a different way Some moms are more withdrawn while others are more active Depending on the mom's interaction style, the babies with display asymmetry in EEG activation ***So it is very important to support moms and dads EARLY!!

Structure of birth to three- natural environment through every step in birth to three process Step 2. Intake and family assessment- gather contextual information (ex. Family activities, routines, child interests, family ecology, etc.) - Identify activities the child/family likes to do that builds on the child's strengths and interests

- Intake and family assessment- want to understand what parent concerns are and move forward with assessment to determine eligibility - If the child qualifies, they are entitled to move forward with an IFSP

It seems like this area of OT practice is less client centered than others. It's more family centered instead. How do you take into account making it more client centered? Do you guide your goals on normal developmental patterns? - Or is the parent considered an extension of the client?

- Kind of a paradox - Child outcome-oriented in documentation= focus on increasing child development and skills - But working with the entire family

Coaching takes a lot of practice - Going through the SAFER allows you to have a guide of questions in front of you

- Lets you learn a lot more about people than you know before

Insurance Reimbursement - Attachment drives child-development so if you don't work with caregiver you won't have good outcomes- so birth to three programs really promote this!!! - So everything you do has to be of the benefit to the child - If you are talking to mom about the fight she had with her husband and how that impacted ability to soothe child during the fight- this counts as part of the session for child development

- Medicaid makes it clear what is a billable moment and what is not - commercial insurance can make choices about what they cover - most private insurances don't cover birth to three unless there was an incident that caused a deficit Federal funds are given to each State which then divides up money to each county to run birth to three - If insurance doesn't pay, we can draw from this money

Models About Human Occupation - Consider the interaction between the person, the environment, and the task/occupation. The profession has multiple models now.

- Model of Human Occupation (MOHO) - Person-environment-occupation-performance (PEOP) - Canadian Model of Occupational Performance and Engagement (CMOP-E) - Occupational adaptation

Primary Coach Approach to Teaming practices Encompasses 3 areas

- Natural learning environments - Primary coach teaming practices (primary service provider) - Coaching practices

What are aspects of co-regulation How to Co-regulate

- Provide warm, responsive relationship - Structure the environment - Teach/coach self-regulation skills

Structure of birth to three- natural environment through every step in birth to three process Step 5. Service Delivery and Transition- point out children's natural learning activities and discover together the "incidental teaching" opportunities that families do naturally between the provider visits

- Service Delivery and Transition - transition to School setting-

Co-occupation Involves 3 aspects (Davel Pickens & Pizur-Barnekow, in review) - Shared physicality- reciprocal motor behavior. - Shared emotionality-reciprocal responsiveness to emotional tone - Shared intentionality-mutually established goals; at the most complex level there is role reversal - Shared physicality details!!

- Shared physicality (maybe someone talks, moves, baby opens their mouth, nursing (mom holds baby close, baby has rooting reflex and turns toward mom's breast/bottle for feeding) ---doesn't have to always involve physical touch!!! Can include a gesture like "SO BIG!" when 2 or more individuals engage in reciprocal motor behavior. For example during breast feeding, we know the mother and baby are sharing physicality because we can observe the shared motor behavior of both the mother and infant, Throughout the feeding/eating process, the mother and infant are actively involved in the process. We come to understand the co-occupational process of feeding and eating because we observe reciprocal motor behaviors or shared physicality that indicate or depict this process.

COACHING---help mom become more self-aware of what she likes and doesn't like what is happening

- So often this changes IFSP outcomes - We need to do routine-based IFSP outcomes that are actionable for increasing child/family participation in routine - "During mealtime, Johnny will pick up the spoon" - different than reimbursable goals - IFSP outcomes more participatory

PCATT used in birth to 3 in Wisconsin IDEA= federal law - States birth to 3 need to be provided with an EBP model PCATT is an example of a EBP model - Family centered - A multidisciplinary team but select a primary service provider who uses coaching as a form of intervention to build capacity of parents - This is different than a lot of models - think of the Verizon commercial- have an entire team behind you but one person is the head of the team Ex. In Eva's team, the OT is chosen as primary service provider

- The OT has a global view of understanding the whole child and their development - The focus she will be working on is based on family needs - She will be providing ongoing service for the child - Whatever mom's focus is determining delivery of services - OT is expected to work on some core issues and mobility if mom wants her to walk - The position as the OT may go back to her team and specifically say to the PT what is it specifically I should focus on for walking- this is how she gets team input- OT then goes back to home therapy and conduct observation- then may want to have PT come with her to the next home visit- so PT and OT may be working together with family ***So OT is still there providing and learning about strategies as the primary service provider even though PT is in home too- and helping the implement them

Still Face Paradigm A YouTube clip A common paradigm in psychology- babies are extremely responsive to emotion and reactions from parents Mother sits down and plays with 1 year old baby - Mother gives greeting to baby and baby gives it back - Mother tries to engage with baby and coordinate their emotions and their intentions in the world - When the mother does not respond to the baby the baby very quickly picks up on this

- The baby tries their hardest to get the mother's attention back ***The baby feels the stress and feels dysregulated - the good is that the normal stuff that goes on with our kids What happens to the baby and how the baby gets dysregulated and there is a disruption in co-regulation

IFSP paperwork at a minimum needs to be updated every 6 months

- This often happens more often b/c of child progress and changes in focus of intervention - Most children pick one skill to work on at a time- according to child development

Could you talk about how coaching families is similar or different to coaching other team members?

- Want to coach ourselves in early intervention team in the same way we would coach families - We have same expectations that they use same format- help me understand what is happening, what do you need my services for, why are you concerned, and what have you tried, then create action plan - To experience coaching - ask closed-ended questions ("did you go to the store today?") vs. open ended questions "how was your experience at the store today?" to get very different responses

Infant Mental Health Intervention • Videorecording or observations. - Was the baby distressed by sensory aspects in the environment?

- Were the mom and baby co-regulated? • Or were they dys-regulated and escalating

Parent and family involvement is huge in birth to three- attachment drives child development!!!

- When a parent & child dyad don't mesh well, development suffers

Birth to 3= a Parent-driven program ****So what the parent desires- this drives who becomes the primary service provider - This is a conversation- what are the options, and what would you like to do - A lot of informed consent to make sure the parents are comfortable and getting what they need - Want the primary service provider a Good "FIT" for the family

- Will look at the global picture (ex. Down syndrome is a long-term disability- and we know long-term the impacts are mostly cognition)- so focus of intervention will likely be education so teacher will likely be primary service provider - Also a primary service provider does switch at times, b/c sometimes family's focus switches, and sometimes child excels so the focus changes - Birth to 3- a relationship-based intervention- so want a provider to be able to build relationship with family-want to build trust and confidence with parents - this is how you make progress

***There is another aspect of co-occupation found and being developed is SHARED COMMUNICATION

- Within co-occupation there is shared communication - A part of physical gesturing (overlap of the rest of the aspects)

How does the transition work from 0-3 to the school system? Do goals carry over? Do the two systems collaborate at all?

- if the child is 2 years 3 months and receiving birth to three and we might think they need to continue services, we notify school system - Then at 2 years 9 months we make actual referral and meeting with school - For children already receiving birth to three services - this ensure smooth transition to early childhood- but they don't automatically qualify for early childhood services even if they are receiving birth to three - Birth to three (family-driven) is completely different than early childhood (child educational attainment is focus)- the system drives much more what children are eligible for Birth to 3 do collaborate with early childhood b/c transitions are hard especially for children with disabilities - This helps to make transition easier

Structure of birth to three- natural environment through every step in birth to three process Step 3. Child evaluation & assessment - gather information on child's FUNCTIONAL behavior- not isolated skills - Observe the child in multiple natural settings using parent's input on child's behavior in various routines and activities

- move forward with assessment to determine eligibility

- reciprocal responsiveness to emotional tone—does NOT have to be the same emotion could be shared positive emotion and expression Doesn't mean emotion is equivalent just means response to emotion Shared emotionality is when one individual is reciprocally responsive to the other individual's emotional tone. Shared emotionality and physicality may be linked. For example, research describing breast feeding depicts the close link between shared physicality and the emergence of shared emotionality Newborns latch onto the mother's breast which is a form of shared physicality. This motoric act creates a release of oxytocin in the mother. Oxytocin is a hormone that fosters attachment and bonding in the mother or emergence of shared emotionality, and this initial bonding leads to the shared physicality of continued nursing..

Birth to three= An entitlement program--what does this mean??

- so if children meet eligibility requirement they are entitled to services - Means you CANNOT have a waitlist

- there is SOME GOAL in mind An infant's goal is to capture the caregiver's ATTENTION! This is their goal- at a very essential level This increases in complexity as a baby gets older Now as adults we can easily switch roles (Ex. Switching from a student to instructor role) - this is intentionality and is highly complex These aspects are essential in infants and may not be as complex but progress to complex switching of roles See this development in complexity with time In infancy and early toddlerhood- the adults are leading the way in these interactions - It is more one-sided occurs when there is an understanding of each other's role and purpose during engagement of the co-occupation. According to Freeman (1995) intentionality is created in the brain by anticipating what will occur from goal-directed actions. Shared intentionality requires that two individuals have mutually established goals and that the individuals understand the other person's behavior as goal directed

Birth to 3- a relationship-based intervention- so want a primary service provider to be able to build relationship with family

- want to build trust and confidence with parents - this is how you make progress

The idea children can thrive and develop despite high risk factors such as trauma and adverse childhood experiences is called -- a theory --resiliency --neuroplasticity --neurodevelopment

--resiliency

The role of parental behavioral health issues and infant mental health Maternal and Paternal PPD

1 in 9 women will experience postpartum depression. More common in men who have a history of depression or financial difficulty Loss of appetite, inability to sleep. Feelings of worthlessness, shame, guilt or inadequacy, Diminished ability to think clearly, concentrate or make decisions

When do babies start to walk? 3 mo 6 mo 18 mo Right at birth

18 mo The range for when children start to walk is the biggest for any milestone (creeping, reaching, grasping, sitting) Each has its own expected age it should be achieved Anywhere from 9 to 18 months walking is expected!!

Co-occupation Shared occupations - can you identify these aspects in the Youtube clip? - shared physicality - shared emotionality - shared intentionality - shared communication 2 twin babies bobbing heads to dad playing guitar

2 twin babies bobbing heads to dad playing guitar Physicality- moving around gestures, smiling, mom laughing Emotionality- positive emotional response from babies, and parents Shared communication- babies gesturing and looking at each other, laughing Intentionality- babies want parents attention but can't switch roles Think of going in a bus shelter and getting on a bus - whether this is a co-occupation or not Riding on a bus and not communicating to anyone, listening to music- you can see the difference here

Approached co-occupation from a lifespan perspective- important across the lifespan in early childhood it is ESSENTIAL Babies not engaged with another individual do NOT exist- they die Brain development occurs in the context of caregiving environment and the attachment relationship

Qualification for birth to three--what qualifies a child for birth to three services?

25% or more delay in one area of functioning - gross motor, communication, social and emotional development, adaptive skills, and cognition - qualify you for services in birth to 3 program Or a diagnosed developmental disability

Rank on aspects.... - Parent changing baby's diaper 1..minimal 2..somewhat 3..moderate 4..high

3... moderate High physicality Minimal shared emotionality minimal intentionality - infant wants to get caregiver attention (will generally cry and show irritation) indicating some level of discomfort indicating need for attention, with the mom having greater cognitive skills- she recognizes baby's cry and know it signals the need for a diaper change ---mom and baby can't switch roles here so intentionality is lower and baby can't take care of mom The baby needs a caregiver so this is why intentionality, while still there is not as complex

How would you rank this co-occupation? - Parent and child exploring a plant 1..minimal 2..somewhat 3..moderate 4..high

3... moderate This is a co-occupation Moderate physicality Moderate intentionality High emotionality This is where the shared communication aspect came about

Rank on aspects..... - Parents and child watering the same plant 1..minimal 2..somewhat 3..moderate 4..high

3...moderate High intentionality Moderate physicality Moderate emotionality

The role of parental behavioral health issues and infant mental health Substance Use Disorders

66% of all Americans age 12 and older have report using alcohol and 17.8% used illicit drugs the year prior to the survey. SUD is when individuals continue to use substances even though the behavior is interrupting participation in everyday life including the ability to perform instrumental activities of daily living such as caregiving

Goal of birth to three

= Help infants meet their full developmental potential - Increase overall participation in overall life- daily routines and functioning with family - Do this through relationship-based practice - Want to build family strength and capacity- do this through COACHING- to build parent capacity to parent their kids

Down Syndrome • Additional chromosome • Short stature • Epicanthal eye folds • Low muscle tone • Arrested and delayed development • Cognitive impairments • Wide range of social, communication, independent living skills, and vocational skills.

A chromosomal disorder Children are generally shorter in stature, epicanthal eye folds, low muscle tone, arrested or delayed development b/c of the low muscle tone and may be cognitive impairments Wide range of social, communication, independent living skills, and vocational skills Mosaic down syndrome are high functioning and cognitive impairments are not so significant Usually those with comorbid severe cognitive impairment generally have difficulty with independent living

Medical Conditions • Traumatic Brain Injury • Cancer and Leukemia • Burns • Traumatic Amputations • HIV and AIDS • Sickle Cell Anemia

A lot of these are related to unintentional injuries from accidents If you work or are interested in a children's hospital Will see kids with TBI - caused by MVA or bicycle riding—one of the highest unintentional injury of childhood --kids can have focal injuries due to a MVA or have more global anoxic TBI due to drowning or hanging insistence A lot of differences in symptoms- much like adults with TBI- children can be similar in their symptoms and depends on their level of injury Anoxic or full brain injury from drowning- their injuries and symptoms tended to be worse Cancer and leukemia - the "hot" unit - a lot of times the children are immunocompromise Take toys and they would stay in the child's room and wouldn't use them with other children just as a precaution Burns- a lot of OT treatment is to increase ROM and promote healing -passively stretch and massage to decrease scar tissue and measure for burn sleeves Traumatic amputations- (ex. Kid playing with fireworks needed an amputation) HIV/AIDS- looking at precautions- the stage of the disease --if they have acquired AIDs may be immune compromised Sickle Cell Anemia- RBC form a sickle and these are really painful b/c can't flow through blood vessels easily

Milestone Moments Booklet

A very popular item is the Milestone Moment booklets. These booklets include the milestones and anticipatory guidance for parents so that they have a list of activities that promote development. A lot of people like milestone moment booklet b/c it is more comprehensive- has activities, and points to talk to the doctor Milestone Moments Booklet • Includes: - Complete milestone checklists (2mo - 5yrs) - Activities to try at home - Space to write down questions • Intended for parent use throughout a child's early years • Helps parents prepare for well-child visits; gives you a parent-friendly reference Milestone Checklists • Complete checklists address - Four domains of development - Developmental "red flags" - Can be printed with Spanish translation on reverse

ADHD • Inattention, hyperactivity and impulsivity • Tends to show up when children begin school • May be effectively treated with medication and/or behavioral intervention • Some treat with diet and exercise

ADHD- have difficulty with attention- may be very motor active and impulsive Ex. During tasks, the child could not sit still to do the screening tasks - had to be standing up or moving while doing the task Tends to show up when children begin school- usually not diagnosed as early as autism Can be treated often with medication and/or behavioral intervention --often start with behavioral intervention first then turn to medication A diet of a lot of sugar could increase symptomatology of ADHD

Evaluation and Screening definitions

AOTA defines screening as "the process of obtaining and reviewing data relevant to a potential client to determine the need for further evaluation and intervention." AOTA defines evaluation as "...the process of obtaining and interpreting data necessary for understanding the individual, system, or situation." - Note: screening typically comes first. - Screening & Evaluation- They are different processes and are used differently with pediatrics

What is this reflex? When an infant turns their head to one side and one arm comes out STNR Moro ATNR Rooting

ATNR ATNR is Silverman's favorite reflex!!! When they turn their head to one side and one arm comes out Skull side arm bends and skull side leg bends Helpful to develop eye hand coordination Don't have great near vision so learn that they have their hand there and can touch things ATNR is meant as a reflexive, protective response ***KNOW reflexes in the chart

Coaching 4 components of coaching Action - Development of joint plan of what going to do between coaching sessions as a result of current conversation

Action- development of joint plan of what you are going to do between coaching sessions as a result of current conversation Coaching takes a lot of practice - Going through the SAFER allows you to have a guide of questions in front of you - Lets you learn a lot more about people than you know before

Activity Analysis and Observation leads to Activity modification and grading!!

Activity Analysis and Observation leads to Activity modification and grading!! - Activity analysis will inform activity modification and grading Do they need a different scissors or table, do they need to stand?

Additional Features of Milestone Tracker App • Notifications • Appointment notifications/reminders • Recommended developmental screenings • Milestone notifications • Recommendation notifications

Additionally, the App provides notifications and reminders for appointments, recommended developmental screenings, milestones, and other recommendations. As a child ages up to the next milestone checklist, the parent will be notified that they have to complete a new checklist. Parents are able to add appointment reminders and can write quick notes on what they want to share with the doctor. Also, if the child is receiving EI services, therapists can add all their questions directly in the App if they aren't able to attend the meeting with the doctor so the parent is prepared to ask the questions. Get reminders that it is time to go through a checklist with the child

CDC's Milestone Tracker App My Child's Summary • Talk with the child's doctor • Referral to a specialist ---Developmental pediatricians ---Child neurologists ---Child psychologists and psychiatrists • Request a free evaluation ---Child Find evaluation ---MD referral and/or medical diagnosis not required ---Early intervention: 0-3 y/o ---Local public elementary school: 3+ y/o

After completing the child's profile and filling out the checklist, the parent will be provided with a summary page of their child's areas of strength and areas of concern. This summary can be shared with the child's doctor or other care providers through email. This section has a link that directs parents to information on early intervention, referrals, and evaluations. Parents are educated that they can request a free evaluation (without the requirement of an MD referral or medical diagnosis) through EI services if their children are younger than 3 or at a local public elementary school if their children are 3 years or older (through the Child Find requirement). As occupational therapists, you can fill out the checklist for the parent on your phone or a classroom or provided iPad, email it to parent, and then delete it afterwards. Remember if a parent does have a concern, Child Find- is a LAW!!! It states that all children, if a parent has a concern, all children have a right to screening and evaluation --this is another resource for parents if physicians have a "wait and see" attitude Parents can contact that resource center and get evaluation for child w/o a doctor's order

Coaching 4 components of coaching Alternatives - Opportunity to consider variety of possible options to obtain desired results

Alternatives- what do you think you could do about it- have you tried anything different? - Coaching really facilitates reflection- putting parent in the driver seat to make those decisions

Components of an evaluation and screening ¡ Child and family centered ¡ Therapist background / expertise ¡ Outcome of the screening process -- Refer family to appropriate services ¡ Outcome of the evaluation process --Part of a diagnostic team --Eligibility for services and resources

Always child and family centered Have to go with the background/expertise of OT- need to have expertise in area they are evaluating outcome of screening-Refer family to appropriate services outcome of evaluation-not just referring, Part of bigger diagnostic team, and say if the child is eligible for OT and how much of it

Coaching 4 components of coaching Analysis - Examines whether what is happening is what is desired - What is known about about child development/evidence-based practices

Analysis - Then analyze whether that person is happy with how the routine works? And what is not working well in the routine

Elements of ASQ-3: Shows hierarchy of questions 1 .Does your child point to, pat, or try to pick up pictures in a book 5. Does your child imitate a two word sentence 6. Does your child say eight or more words 5 and 6 are seen in most childrenof the 16 month domain Elements of ASQ-3: Overall Section Some parents want to include qualitative info - this section is unscored

Any concerns or questionable responses require follow-up •Yes = 10 points, Sometimes = 5 points, Not Yet = 0 points •Transfer scores to Information Summary page •Compare child's score in each area to cutoff score; cutoff scores based on empirical research ØScores falling in the white area indicate the child is developing typically ØScores falling in the gray area mean the child should be monitored and another screening may be desirable in a few months (1 -2 SD below the mean) ØScores falling in the black area mean the child may be at risk for developmental delays and should be referred for further assessment (2 SD below mean) •Children with autism were included in the normative sample

Reminder! • Developmental Milestone Checklists are NOT SCREENING TOOLS nor are they indicators of developmental delay or disability. • They are designed to engage parents in monitoring children's development and to help staff and parents decide when to refer to the child's health care provider, EI or Special Education Services.

As an Act Early Ambassador, I have spoken with many professionals who believe that the Milestone Checklists are an actual screening instrument and it is important to note that the checklists are NOT a screening instrument. Checklists are designed to engage parents in monitoring a child's development and to help facilitate a referral for screening if there are concerns. Referrals to the child's PCP, EI or Special Education Services should be made if a child is missing Dev. Milestones. Have what children should be doing at that age 2,4,6,9 months

CDC's Milestone Tracker Mobile App Relatively new app Has all of the aspects of the milestone moments booklet in there

As you can see on the left side of the screen, parents enter the name/names of their children and their DOB. After that, parents will see a screen like the one on the right which includes a milestone checklist when to act early, tips and activities to promote development a quick view of the milestones and the child's summary. What It adds is the video clips Limitations of the app - Need a smart phone - Need wifi - ***This is why having a variety of materials is really helpful

Associated Problems of Neural Tube Defects • Meningitis - high risk of infection from the exposure of the meninges and spinal cord through the myelomeningocele and surgery • Hydrocephalus • Arnold - Chiari Syndrome - slippage of the brain through the foramen magnum can result in further motor dysfunction and cerebellar signs

Associated problems with neural tube defects Meningitis b/c there is a high risk of infection due to exposure of meninges and SC Hydrocephalus- where CSF is not draining properly - usually shunted to drain to abdomen Arnold-chiari syndrome- can cause further motor dysfunction- where brain slips through foramen magnum

Neuro- Developmental Conditions • Autism Spectrum Disorder • Down Syndrome • ADHD • Intellectual Disabilities • Learning Disabilities • Sensory Deprivation / Attachment Disorder • Prenatal Substance Exposure • Maternal infections (CMV) • Environmental conditions

Autism Spectrum Disorder- we will have a whole unit on this- difficulties w/ social communication and repetitive/restrictive behavior patterns Down Syndrome- a genetic condition, there are different types of Down syndrome, (ex. Mosaic down syndrome have high intellectual disabilities) additional chromosome ADHD ID- have issues with adaptive functioning Learning disabilities often don't show up in their true form until school- dyslexia or non-verbal Sensory deprivation/attachment disorder Prenatal substance exposure- there is a challenge with opioids - really affecting babies Maternal infections (CMV)- involved with changing cat litter boxes - pregnant women shouldn't do this, Environmental conditions can impact a child's growth and development like pollution

Coaching 4 components of coaching Awareness- - Promote awareness of what coaches already knows or is doing - How effective current strategies are

Awareness- You increase self-awareness of the routine

Which question provide information regarding a child's community mobility? A) What is the level of supervision provided? B) Can the child leave the house and play with friends? C) Is the child being bullied? D) Is there equipment available so the child can play with peers?

B) Can the child leave the house and play with friends?

Which question does not provide information regarding the family's cultural values? A) Who makes the decisions? B) What is the child's date of birth? C) What are the daily routines and rules of mealtime? D) What do the parents believe about disability?

B) What is the child's date of birth?

Compare Scissors Activity ¡ Chapter 6 Resources ¡ General Activity Analysis - Cutting § Box 6.8 ¡ Client Focused Activity Analysis § Video Clips - Chapter 6 This is the activity analysis the OT goes through- of cutting Finds out Jack cannot cut like the other kids so we need to observe him doing the activity The steps are listed out already- what is needed, what are the body structures and functions A lot of stuff to go through at once

Be able to sit still, visual function, determine orientation of scissors, cognitive function (scissors are used in one hand), adjust the force to pick up the scissors, differentiate grips from blade, need all those muscle functions ****A big one is shoulder and elbow stability, joint function, also the contextual requirements needed to complete activity ---this is all for just picking the scissors up!!!

Birth to 3 is a federal and state mandate- comes from IDEA - This is part C of IDEA

Birth to 3 is a federal and state mandate- comes from IDEA - This is part C of IDEA - Early childhood is part B - Means any government program has lots of rules and regulations - Department of Health and Human Services (DHS) administrative code 90- codes (birth to three framework and what you have to abide by ***

Pediatric Practice ¨ Context ¤ Birth to three - natural environments ¤ Early childhood programs ¤ School based practice ¤ Hospital settings ¤ Outpatient therapy settings

Birth to Three OT services provided by COUNTY - These end immediately after 3 years old Any OT service AFTER 3 provided by SCHOOL Early childhood programs- comprises around 3-5 years old School based practice = ages 3 to 21 Considered by law = 0 to 21 that children can receive services through the county or school district

Linda Wetzel guest speaker- talking through practice-based pieces in real life - Birth to 3 coordinator for Waukesha county OT degree from UW-Madison Lutheran social services works with Waukesha county to provide birth to 3 program

Birth to three is from ages 0 to 3 provided through the county 3 years qualifies them for services through the school In Wisconsin, parents can request services without a MD referral Parent and family involvement is huge in birth to three- attachment drives child development!!! - When a parent & child dyad don't mesh well, development suffers Birth to three really went through a paradigm shift There has been a shift to provide birth-3 in naturalistic settings - Working with kids in their homes with parents and families Relationship-based program- trying ot increase child participation in natural environments - Focus on child and family strengths and using a coaching approach Birth to 3 is a federal and state mandate- comes from IDEA - This is part C of IDEA

What is the "purpose of OT"? • To support, hold and nurture children and their caregivers. - Gain knowledge about risk factors for chronic stress. • Birth related maternal mental health.

Birth-related trauma may decrease a mother's health and well-being

What does science tell us? Child's development Brain development occurs within...

Brain development occurs within the context of the caregiving environment and the attachment relationship - Infants whose mothers have depression display asymmetry in EEG activation. Dependent upon interaction style - those with intrusive interaction styles have higher activation of the left frontal region and those with withdrawn interactions have higher levels of right frontal lobe activation (Diego, Field, Jones & Hernandez-Reif, 2005)

How does trauma impact infant and toddler health? • Trauma effects the structure and function of the brain • Early brain development responds to environmental affordances. • The brain is plastic and malleable to experiences.

Brain is very plastic in childhood Trauma has lasting effects Brain does respond to the environment The "Reflex of Purpose" Van Der Kolk, • "All creatures need a purpose-they need to organize themselves to make their way in the world, like preparing a shelter for the coming winter, arranging for a mate, building a nest or home, learning the skills to make a living. One of the most devastating effects of trauma is that it often damages that Reflex of Purpose. How do we help people to regain the energy to engage with life and develop themselves to the fullest?.......This invites us to focus on emotions and movements not ....as problems to be managed, but as assets that need to be organized to enhance one's sense of purpose."

Which statement best reflects a top-down approach to the evaluation process? A) OT focuses evaluation on child's poor performance with hand skills. B) OT completes assessment to provide a motor age for fine motor and gross motor skills. C) OT begins by interviewing family regarding routines, interests, and daily habits. D) OT begins by examining muscle tone, postural control and range of motion.

C) OT begins by interviewing family regarding routines, interests, and daily habits.

Which statement does not reflect how an occupational therapist uses clinical guidelines to inform practice with children and youth? A) Modify guidelines to fit the specific environment B) Establish systems to monitor outcomes C) Select the most recent guidelines without considering client D) Consider guidelines that fit one's clientele and environment

C) Select the most recent guidelines without considering client

Co-occupations are the most interactive of all social occupations

Central to the concept of co-occupation is that two or more individuals share a high level of physicality, emotionality, and intentionality

What is chronic or toxic stress (harmful events)? • Stress isn't all bad and can actually promote growth and development. - Separation anxiety - Starting pre-school • Repeated or long-term stress increases the risk for poor physical and behavioral health.

Chronic or toxic stress Stress is not always bad Some level of stress can promote growth and development There is stress in separation anxiety with babies- but if the stress is not prolonged and their needs are met- doesn't cause chronic or toxic stress The change in home-school - not really sure if that will be toxic or chronic stress

Ethical Considerations • Examiner competency • Client privacy • Communication of test results • Cultural bias ***Client privacy

Client privacy- is always an issue and is trickier with kids

What is co-occupation?

Co-occupation means mutually engaging in purposeful daily activities that hold meaning. "Those that implicitly involve two or more individuals are termed co-occupations (Zemke & Clark, 1996). Co-occupations are the most interactive of all social occupations. Central to the concept of co-occupation is that two or more individuals share a high level of physicality, emotionality, and intentionality

Brain development is related to the habits and routines that occur within the context of the caregiving environment (

Co-occupation was not even mentioned in the literature NOW In the AOTA practice framework This is the first time co-occupation has been recognized in AOTA documents Wanted to recognize engagement with other people in children Approached co-occupation from a lifespan perspective- important across the lifespan in early childhood it is ESSENTIAL Babies not engaged with another individual do NOT exist- they die Brain development occurs in the context of caregiving environment and the attachment relationship

Childhood Occupations

Co-occupations lead to childhood occupations and independent functioning

Ethical Considerations • Examiner competency • Client privacy • Communication of test results • Cultural bias ***Communication of test results

Communication of test results- assessment scores are only to be shared with physician, and PARENT or LEGAL GUARDIAN, and teacher- nobody else can get these results unless you get permission from legal guardian or parent

Once you've done interview and activity analysis you will better determine which standardized assessments you need

Components of Pediatric Evaluation Interview observation standardized non-standardized assessments- make up a pediatric evaluation

Components of Evaluation • Interview Rating Scales Occupational Interview • Observation Activity Analysis Ecological assessments • Standardized Norm-referenced Criterion-referenced • Non-Standardized Similar to adult evaluations ***But a big difference is we can do in pediatrics= observations in their NATURAL ENVIRONMENTS- schools, in the home, or in community, or even in clinic

¡ Validity Validity Validity is the extent to which a test measures what it claims it measures Construct-Related Validity

Construct-related validity is the extent to which a test measures a theoretical construct. Some constructs frequently measured by pediatric occupational therapists include fine motor skills, visual-perceptual skills, self-care skills, gross motor skills, and functional performance at home or school

¡ Validity Validity Validity is the extent to which a test measures what it claims it measures Content-Related Validity

Content-related validity is the extent to which the items on a test accurately sample a behavior domain

What are contributing factors to the mental health of an infant or toddler? • Factors related to the child that place the child at risk. - Disability - Prematurity - Regulatory disorders - Chronic or toxic stress

Contributing factors place children at risk Medical conditions we discussed before can prevent social-emotional development Their disability can make reading cues difficult When babies are born premature, the likelihood the parent will experience depression/PTSD increases significantly Regulatory disorders - a colicky baby or difficulty self-regulating can be a problem - it creates a problem within that relationship Chronic or toxic stress is more related to the environment

¡ Validity Validity Validity is the extent to which a test measures what it claims it measures Criterion-Related Validity

Criterion-related validity is the ability of a test to predict how an individual performs on other measurements or activities To establish criterion-related validity, the test score is checked against a criterion, an independent measure of what the test is designed to predict. The two forms of criterion-related validity are concurrent validity and predictive validity.

Ethical Considerations • Examiner competency • Client privacy • Communication of test results • Cultural bias ***Cultural bias

Cultural bias in assessment- there is cultural bias in almost all assessments available (ex. Not using buttons, or not using a scissors till 5 years old) - have to take this into consideration - have to ask parent- does the child saying this word mean what it normally means?

Which statement best describes the recommended approach to increase participation as the focus of occupational therapy intervention with children and youth? A) Remediate areas of concern and the child's limitations B) Intervene with family and friends so they interact differently with child C) Promote the child's strengths and allow child to accommodate to challenges D) Evaluate the child's areas of competence and achievement, along with challenges

D) Evaluate the child's areas of competence and achievement, along with challenges

DC:0-5 System - Assessment/Intervention Axis I-V Axis I- Contribute to diagnostic team Axis II- Assess the dimensions and environment Axis III- Educate - professionals and families about the role that health conditions play on SE Dev. Axis IV- Assess stressors Axis V- Evaluate

DC 0-5 system Axis I - primary diagnoses (we contribute to the diagnostic team) Traumatic stress, disorders of affect, adjustment Axis II- relational context- we can examine the caregiving dimensions and environment Axis III- physical health conditions- we can educate the role health conditions can play on development Axis IV- assess stressors- related to ACE questions- we are mandatory reporters Axis V- we actually evaluate developmental competence (ex. Milestones) **See how OT fits into infant mental health

CP Terminology Describing muscle tone • Spasticity • Flaccid / Hypotonia (Pedi-neuro exam) • Athetoid / Dystonia • Ataxic Describing severity • Mild • Moderate • Severe Describing limb and body involvement • Quadriplegia / Tetraplegia • Paraplegia • Diplegia • Hemiplegia

Describe muscle tone - - spasticity (high tone in arms/legs, and low tone in trunk), - flaccidity and hypotonia (very low tone- have a hard time if they are in supine working against gravity, may not be able to hold up their head), - athetoid/dystonia- (lack graded movement- don't have graded motor control to reach for something), - Ataxia- (like a quivering jerkiness that a child will demonstrate- affects balance and ability to stand - a little jerky in their movement) Can see a range of muscle tone from mild to severe Description of limb and body movement Tetraplegia (limb involvement of all extremities) Paraplegia (lower extremities Diplegia (mostly lower extremities and less severe upper involvement) Hemiplegia (involves one side of the body)

Developmental Monitoring vs. Developmental Screening

Developmental Monitoring - Done by parents, teachers,health professionals - Ongoing process-begins at birth - Sample tool: "Learn the Signs. Act Early." Milestone Checklists Both: - Look for developmental milestones - Important for tracking signs of development and identifying concerns Developmental Screening - Formal process - Recommended by the American Academy of Pediatrics at 9, 18, and 24 or 30 months - Done by health professionals and may be done by teachers with special training - Uses a validated screening tool - Sample tool: Ages and Stages Questionnaire Developmental monitoring + screening = more kids in early intervention compared with DS or DM alone!

The Learn the Signs. Act Early campaign is a health communication campaign aimed at increasing developmental monitoring!!!

Developmental monitoring is different from Developmental Screening in that DM can be completed by parents, teachers, and health professionals. It is an ongoing process that begins at birth. In comparison, DS is a formal process using a validated screening instrument and is typically completed by or with health professionals or professionals who are trained in psychometric properties of screening instruments. The AAP recommends that every child receives developmental screening at 9, 18, 24 or 30 months and an example of a DS instrument is the Ages and Stages Questionnaire. Both DM and DS identify the presence or absence of dev. Milestones and they are important for tracking the signs of development and identifying concerns or red flags. ***A study by Barger and colleagues showed that DM + DS identifies more children with concerns than DS or DM alone

***The best approach is developmental monitoring and developmental screening TOGETHER is the best way to ID children early

Developmental monitoring takes place over a long period of time- with parents, teachers, HCP - can be done with-is ongoing (like making a quilt) Developmental screening- usually done by a healthcare professional - Is a more formal process- if parent has a concern about LTSAE materials- then child should be screened - HCP goes through and scores different areas then go forward for further evaluation - Parents aren't always listened to so LTSAE helps HCP take their concerns seriously

Steps for screening and surveillance • Perform the 6 steps of developmental surveillance at each health supervision visit: - 1.) review checklists/developmental history; - 2.) ask about concerns; - 3.) assess strengths and risks; - 4.) observe the child; - 5.) document; and - 6.) obtain and share results with others (early childhood educators, WIC providers, home visitors, etc.).

Developmental monitoring--if you are working with primary care or pediatrician- they consider developmental monitoring within the realm of developmental SURVEILLANCE---they engage in these 6 steps Step #6- Share results with others involved in childcare (WIC program, home visitors, early childhood educators)

Muscular Dystrophy • Progressive degeneration and weakness of the muscles. • Duchenne's MD is the most debilitating, the most progressive and the most common • Affects boys because it is a recessive X linked disorder. • Lack of production of Dystonin which is necessary for muscle function.

Duchenne's MD- most debilitating, common, and most progressive AOTA has training for early identification of MD- it is progressive and debilitating Our interventions are around maintaining muscle strength and preventing deformity and contracture

Reason for developmental and maternal mental health screening ¡ Early identification = optimal outcomes ¡ Reassure parents ¡ Link child and family to services

Early ID for the MOTHER & BABY!!! Reassure parents- pretend like the parents are accountants or work in any other field other than child-focused fields- help them understand what is typical and what is not Link child and family to services - referral—steps to assist in diagnostic process

Eating a Taco How would this look different if it were a child versus an adult?

Eating with a hard shell wouldn't probably be given to a toddler Our occupational engagement shifts as we get older Points to cover: Discovery focused Kids want to eat Messy vs. clean Picky Interactive Play with food Refined skill: children still exploring can almost see the problem solving taking place, written all over their face

The ACE Study

Effects are cumulative of ACES Children who experience ACES can experience social, emotional, cognitive impairment, can engage in high-risk health behaviors, are more likely to acquire disease/disability as adults, and this can lead to early death

Keypoints to Remember • An infant mental health approach is embedded in RELATIONSHIPS!! • Infants and toddlers can experience mental health challenges/disorders • We are frontline service providers who can provide assistance and help to infants, toddlers and families • There are resources available - WI-IMHA, AOTA

Embedded in your relationship with the parent/caregiver and embedded in the dyadic relationship of parent and child Relationships are at the heart of infant mental health We are the front line service providers that can help provide families and children with infant mental health resources Wisconsin Alliance of Infant Mental Health (WI-IMHA)

Encephalitis and Meningitis • Encephalitis • Meningitis

Encephalitis- boy developed this as a secondary infection after having chicken pox infection- settled into his brain --child had motor deficits - fine and gross And some cognitive deficits but his case was relatively mild Inflammation of the brain - Meningitis - different types - some are fatal Recommend for undergraduate students to get vaccinations b/c bacterial meningitis can be fatal!!! Viral meningitis- the person may feel ill but generally not a fatal disease A communicable disease- so if someone does become ill with meningitis it needs to be reported just like with COVID-19 to do contact tracing

Intervention ***Create/Promote - This approach designed to provide enriched contextual and activity experiences that will enhance performance for all people in the natural contexts of life Ex. STEAM activities (STEM with art)

Engaging in horticulture activity- co-occupation STEAM activities STEM with art Help promote co-occupation and development

Newer Developmental Thinking Developmental trajectories can be - Typical - Delayed - Slowed - Delayed and slowed - Nonlinear or - Initially typical followed by a "falling off"

Enriched experiences can help a child grow even when a premature baby who is on a non-linear developmental track Delayed and slowed-- can be taken within context Delays can actually mean eligibility for service (ex. 25% delay) Slow means they might be developing at a slower pace but they are not outside that range

Reasons for Evaluation ¡ Referral to specialists ¡ Determine eligibility for services ¡ Assist with the diagnostic process ¡ Collect information to guide intervention planning ¡ Compare performance from baseline ¡ Make decisions about the effectiveness of an intervention

Evaluation is Not just referral to services- but a part of it Can assist with diagnosing a disability - Either in a medical or educational setting- we have an impact on both of these Compare to baseline to determine if the child made progress- is the intervention effective

Intervention Planning (we'll get to this later)

Evaluation leads to... Goal writing (person, timeframe, occupation, context) leads to... Intervention planning

Why "Learn the Signs. Act Early."? • About 1 in 6 children aged 3-17 has a developmental disability (Boyle et al, 2011). • Up to 13% of children aged birth to 3 years old have developmental delays that would qualify them for Part C, based on common state eligibility criteria (Rosenberg, Zhang, & Robinson, 2008). • Only 2-3% of children receive early Part C intervention services, and between 5-6% receive early childhood special education services through IDEA Part B, Section 619 • Data related to Part C/Part B enrollment suggest that many children with developmental disabilities may not be identified in time to access early interventions. (Early Childhood Technical Assistance Center, n.d.; Macy, Marks & Towle, 2014). • Failure to identify children with developmental delays before their 3rd birthday reduces the likelihood that the child will receive the benefits of Early Intervention services.

Even though 13% of children qualify for EI, only 2-3% receive early part C intervention series Ages 3 to 5 only 5-6^% receive early childhood special education services Aren't accessing EI or early childhood special education services - Marginalized communities experience disparities in early identification

Ethical Considerations • Examiner competency • Client privacy • Communication of test results • Cultural bias **Examiner competency

Examiner competency- Competency in their field and the assessment (that's why you need to practice assessment, and may need training in certain FOR)

The CDC indicates that 75-90% of all children at the age of the checklist should be hitting all of the listed developmental milestones

For example, the 6 month checklist is presented on this slide, 75-90% of all children should be demonstrating the skills listed in SE, Lang, Cog, motor development. These checklists can serve as a credible communication tool if a parent goes to their child's PCP and the PCP has a wait and see attitude. The parents can use the checklist to facilitate communication and advocate for a referral on their child's behalf.

• Encourage parents to monitor milestones between visits and share results with you: - Print and post FREE Milestone Tracker app posters pdf icon[387 KB, 1 Page, Print Only]in exam rooms; encourage families to download the app and complete a checklist. - Print and give milestone checklists pdf icon[2 MB, 20 Pages, 508]to families who prefer paper or speak languages other than English or Spanish; laminate and reuse them as needed. • Conduct early childhood screenings as recommended by the AAP, using validated screening toolsexternal icon at recommended ages and if surveillance reveals a concern. • Refer children with concerning results for further evaluation AND to your state's early intervention program.

HCP/physicians are responsible for conducting early childhood screenings (OTs can too!) Then refer children for further evaluation if they have concerns ***Us as OTs can be involved in all 3 steps- developmental monitoring, screening, and referral

Assessments to Know About 0-5 ¡ HELP ¡ Bailey Scales of Infant Development - 3 ¡ PEDI-CAT ¡ PDMS-2 ¡ M-CHAT R/F ¡ ASQ

HELP- criterion referenced- Does your child do this- gives them a sense chronologically Bailey - Assessment that is a standardized assessment that gives you scores you might want PEDI-CAT- PDSM-2 M-CHAT R/F- A disability-specific screening tool for Autism in toddlers - • Two-stage parent-report screening tool to assess risk of ASD (16-30 months) ASQ - general developmental screening tool - looks at all different areas of development as a whole - not specific disabilities

Scissors Activity -Jack Observation video in class OT says "let me help you a minute" she helped him position his cutting hand correctly - he held the scissors better Was worried the child was going to cut himself People are afraid of Fisker scissors b/c they look sharp What are Professor Silverman's recommendations?

Have to pick arms up over the table to do the cutting This makes her shoulder less stable if she is too close to the table Need to put arms right next to their body and sit farther away from table Thumbs up is next cue Then the rest she guides Have to fill out general activity analysis - cutting, then do a client-focused (Sometimes doing a video of the child is helpful

Infancy • Co-occupational engagement • Occupational engagement Early childhood-adult • Overall health and well-being

Healthy co-occupational engagement increases our overall health and well-being

Aspects of Co-occupation-Assessment - Essential to Complex Thinking of a scale within the aspects The more the aspects get to the center of the circle means all aspects are present and it's a highly complex co-occupation!!

High shared physicality - toddler isn't happy about what's on the spoon- wincing, mom is holding spoon Shared emotionality- ranked a little lower - there is some Shared intentionality- this is more one-sided- the mom really wants to feed the child but the child doesn't want it as much

Co-occupation and Co-regulation How to co-regulate

How to co-regulate - Provide warm, responsive relationship - Teach/coach self-regulation skills - Structure the environment Co-occupation is a means to which we can facilitate co-regulation We want to support a warm responsive relationship and also coach/teach self-regulation skills, and structure the environment If the parent becomes upset and gets loud- the child can feel this through mirror neurons ---this is not to blame, but support parents

- Co-regulation and co-occupation are LINKED!!!

How we co-regulate really occurs WITHIN co-occupations Occurs within those shared routines- bathing, feeding, dressing, play Another reason why we should be thinking about co-regulation and co-occupation

Hydrocephalus and Microcephaly • Hydrocephalus - Children are typically shunted at an early age - Shunt malfunction can be fatal • Microcephaly

Hydrocephalus- kids are usually shunted at an early age --Need to really watch and pay attention to shunt malfunction- means CSF is not draining properly ---shunt malfunction may show up through lethargy, not doing same things they are used to, seizure activity, vomiting, looking off If you see this it is really important to talk to parents -and possibly call doctor Microcephaly- A small brain- will take measurements of child skull --saw microcephaly in babies that have been infected with the Zika virus

Intentional Relationship Model (IRM) • advocating, • collaborating, • empathizing, • encouraging, • instructing, • problem solving. • ***The key to effective therapeutic relationships is to practice with mindful empathy, be flexible in mode use and family-centered when applying IRM in practice.

IRM - advocating, collaborating, empathizing, encouraging, instructing, problem solving. KEY is to be flexible in our mode use and what is most beneficial for parent

Developmental Milestone Norms • By the age listed on the milestone checklists: - 75% - 90% of all children at that age should be hitting all of the listed developmental milestones. • Therefore, missing a milestone on the checklist warrants a conversation with a health care provider.

If a parent is raising concern about a milestone- that is very significant!!! b/c that is a milestone that 75-90% of all children achieve Includes activities parents can do with their child to promote development

Assessment • Top down vs. bottom up approach to assessment Top down - 1. Participation - 2. Co-occupation - 3. Activities -aspects - 4. Impairments Bottom up - 1. Impairments - 2. Activities - 3. Performance If we are looking at co-occupation we are looking from which approach!!!

If we are looking at co-occupation we are looking from a top-down approach!!! A top down assessment When Barnekow was trained as a sensorimotor therapist she used a bottom-up approach she looked at impairments for treatment --didn't look at co-occupation b/c never saw or worked with the parents So change in policy has been beneficial Look at PARTICIPATION- what is the responsiveness and then work down to figure out activities Know co-occupations help facilitate co-regulation (activities) What impairments are impeding interaction

Getting LTSAE Materials is Easy!

In addition to the print or hard copies of the materials, the CDC has developed a Milestone Tracker mobile app. The app is free and works on iOS and Android phones. Most hardcopy materials are available in English and Spanish with simplified versions in Chinese, Korean and other languages. Getting materials is very easy Can just google LTSAE and it will come up ****There are a lot of materials but the tough part is learning how to implement these!!! You can give the materials to providers but how they integrate them into practice is another story ***Challenges with implementation b/c asking people to CHANGE THEIR PRACTICE and the way they do things

Infant/Toddler Mental Health • What is infant/toddler mental health? - The World Association for Infant Mental Health defines infant mental health as: "the ability to develop physically, cognitively, and socially in a manner which allows them to master the primary emotional tasks of early childhood without serious disruption caused by harmful life events. Because infants grow in a context of nurturing environments, infant mental health involves the psychological balance of the infant-family system" - The unit of treatment is the caregiver and the child. - Intervention is relationship-based. Bi-directional

Infant mental health really involves psychological balance of the infant-family system Caregiver and child = treatment unit Intervention is relationship-based and bi-directional The relationship between occupational engagement and health

¡ Reliability The three forms of reliability most commonly used in pediatric standardized tests are (1) test-retest reliability, (2) interrater reliability, and (3) standard error of measurement (SEM). (2) interrater reliability,

Interrater Reliability Interrater reliability refers to the ability of two independent raters to obtain the same scores when scoring the same child simultaneously For self-report tests, interrater reliability is generally not a meaningful indicator of the psychometric integrity of the test, because everyone who contributes information to the test does so based on knowledge of the child in a specific environment with unique demands and perception Acceptable Reliability No universal agreement has been reached regarding the minimum acceptable coefficient for test-retest and interrater reliability One standard used by several examiners is 0.80

Remember if a parent does have a concern, Child Find- is a LAW!!!

It states that all children, if a parent has a concern, all children have a right to screening and evaluation --this is another resource for parents if physicians have a "wait and see" attitude Parents can contact that resource center and get evaluation for child w/o a doctor's order

Dynamic Process ¡ Continues formally or informally throughout the relationship with the child and family ¡ Be able to flex your evaluation plan

Just like adult services- you need to adjust the child's evaluation plan Often can't get through an entire evaluation- and may have to continue a different time ***NEED TO LEAVE TIME FOR EVALUATION

Learn the Signs. Act Early. Preparing Parents to Nurture Early Development through Developmental Monitoring

LTSAE - A way for preparing parents to nurture early development through developmental monitoring

"Learn the Signs. Act Early." Mission To improve early identification of developmental delays and disabilities, including autism, by facilitating parent-engaged developmental monitoring and promoting developmental screening so children and their families can get the early services and support they need.

LTSAE actually serves POPULATIONS!!

The LTSAE Approach-Health Communication Intervention • Friendly, positive (and cute!) - Focus on milestones, not warning signs - Celebrating development as important as acting on concerns • Parent-focused • High-quality • Comprehensive • Helpful, encouraging • Open, customizable • Can be used with parents of pre-term infant/s

LTSAE- A public health intervention All families with young children should be focusing on developmental milestones Purpose of this is to celebrate success!! Milestone materials provide support for families to talk about concerns Can be used with preterm babies but need to use ADJUSTED age of the child- not their gestational age

Defining Occupational Performance in Children What is occupation? How does this apply to children? What is the difference between the occupations of children and those of adults? How does this apply to children?

Learning occupations and gaining skills Think about the difference b/w occupations of children and adults --reflect on your own life- ex. In childhood had favorite toys and games Now those are probably not the same

Levels of adaptive functioning - Relational Context Model of Co-occupation Shared physicality, emotionality, intentionality, communication Levels of adaptive functioning (well adapted, strained, compromised, disordered/dangerous)

Levels of adaptive functioning (well adapted, strained, compromised, disordered/dangerous) --well adapted--This is where we need to think about the model of co-occupation --strained--Caregiver has good adaptive qualities --compromised--The parent has some qualities but inconsistent --disordered/dangerous--Very inconsistent adaptive qualities Relationship is fraught with conflict or significant role reversal

Standard Scores- Developmental index scores ****(These are BELL CURVE SCORES) The Human Development Index Score (HDI) is a summary measure of average achievement in key dimensions of human development: a long and healthy life, being knowledgeable and have a decent standard of living. The HDI is the geometric mean of normalized indices for each of the three dimensions Like the deviation IQ scores, developmental index scores have a mean of 100 and a SD of 15 or 16

Like the deviation IQ scores, developmental index scores have a mean of 100 and a SD of 15 or 16. Children who receive a developmental index score of 2 SD below the mean (index score of 68 or 70) in one or more skill areas need remedial services. In many cases children who receive developmental index scores lower than −1.5 SD (index score of 85) may also be recommended for occupational therapy services Used in developmental tests such as the PDMS-2 (Folio & Fewell, 2000) and the Bayley Scales of Infant and Toddler Development

ASQ-3 review Ask what is the parents concerns when they call Early intervention birth to three services Then ask if they can run an ASQ-3 screen to see where the child lies developmentally - Lisa's program they do this over the phone!

Lisa scores 5 areas of development and discusses results with parents - Ex. Hannah is in the gray area in communication skills- what do you think about that? - About increasing parent's awareness and the early intervention service provider - Upon this screening, a child may be identified to need OT evaluation ***ASQ-3 screening tool - Increases everyone's self-awareness and raises awareness of who we should use from the EI team to conduct possible evaluation Discuss scheduling an evaluation if parent agrees

Axis II - Relational Context • Caregiver-child relationship adaptation - 3 characteristics • Caregiver consistently emotionally available • Caregiver values child as a unique individual • Caregiver is comfortable and confident in raising the child **There are actual questions the DC 0-5 has

Looking for the caregiver to be Caregiver consistently emotionally available Caregiver values child as a unique individual Caregiver is comfortable and confident in raising the child **Prematurity can impact caregiver confidence

Intervention- Facilitate co-occupational engagement ***Maintain - Approach designed to provide supports that will allow clients to preserve the performance capabilities that they have regained and that continue to meet their occupational needs.

Maintain—PRESERVE performance capabilities

Interactive Relationship with frame of reference (FOR) ¡ Theoretical perspective ¡ Guides observation ¡ Prioritizes elements of observation

May need to select a FOR based on the setting you use this in May be looking at body structures specifically - ex. Biomechanical FOR Or motor learning/motor control- coaching/teaching

Medical Model • Medical model framework • Medical model permeates cultural bias and belief systems and informs many therapy practices. • The changing paradigm

Medical model- does have cultural biases and belief systems that have informed practice for many years There is a changing paradigm now- the social view of disability- where disability is created b/c of the environment There is this new perspective of disability that disability is a range of abilities and a person becomes disabled b/c the environment isn't supporting their participation ***Still see medical model in a lot of settings we work in

Intervention- Facilitate co-occupational engagement ***Modify - find ways to revise the current context or activity demands to support performance in the natural setting Ex. Miracle League Baseball

Modify - find ways to revise the current context or activity demands to support performance in the natural setting- The caregiver here is modifying the activity to promote participation A co-occupation here b/c there is reliance on caregiver to facilitate participation

The role of parental behavioral health issues and infant mental health Birth related PTSD and trauma

Nine percent of women the United States with up to 18% at risk hyperarousal, avoidance/numbing re-experiencing

The "top -down" assessment. - Occupational Performance --Participation ---Client Factors

Not starting with cognitive skills or body functions? ***Occupational performance is the focus!! Not worried about how they are holding their scissors properly here in top-down assessments- But in some assessments they will ask if the child held the scissor correctly

Co-occupation and occupation in childhood Seeing kids in the clinic in 1997-2000 Was very child-centered in outpatient setting NOW it is what??

Now it is FAMILY-CENTERED--- performed in the child's natural setting with direct parent involvement!!! Many changes in the law and the practice—co-occupation is super important

Activity Observation and Analysis ¡ General activity analysis ¡ Steps § Materials § Context § Activity demands § Possible meanings ¡ Client-focused activity analysis § Personal way in which activity is performed § Unique features of how client does activity

Observational Assessment leads to activity and observational assessment - General activity analysis - need to list out all those steps, materials needed to be present to make it happen, what is the general context, and activity demands social, cognitive, physical, and the meaning of these - Client-focused activity analysis - Personal way an activity is performed ***Often pair general and client-focused activity analysis and find out where the child is struggling Positioning, activity demands may be too difficult

Co-occupation and Co-regulation ******How we co-regulate really occurs WITHIN co-occupations

Occurs within those shared routines- bathing, feeding, dressing, play - Co-regulation and co-occupation are LINKED!!! Another reason why we should be thinking about co-regulation and co-occupation

Standard Scores- Deviation IQ scores Deviation IQ is scored based on how an individual deviates from the average IQ of 100. It measures IQ as a normal distribution with the average IQ being a 100 with a standard deviation of +/- 15. ****(These are BELL CURVE SCORES)

On these tests, individuals with IQ scores 2 SD below the mean (IQs of 70 and 68, respectively) are considered to have an intellectual disability. Individuals with IQ scores 2 SD above the mean (IQs of 130 and 132, respectively) are considered gifted. These are the IQ scores obtained from such tests as the Stanford-Binet (Thorndike, Hagen, & Sattler, 1986) or the Wechsler Intelligence Scale for Children (WISC)

Symptoms and Characteristics of Muscular Dystrophy • Onset • Early signs • Gower's sign • Scoliosis (lordosis and kyphosis are common) • No treatment is currently available. • Life expectancy

Onset is usually early childhood depending on type, Duchenne's is early childhood Gower's sign- a way that the child is getting up- standing up- they essentially use their legs and push themselves up on their legs Imagine a yoga pose where you make a triangle - instead of bending legs to squat to stand up, they put hands on their legs to crawl up b/c of loss of muscle strength- lordosis and kyphosis are common No treatment is available Life expectancy is limited- some of them can be very short - especially with Duchenne's MD

Musculoskeletal Conditions • Osteogenesis Imperfecta • Arthrogryposis • Juvenile Rheumatoid Arthritis • Congenital Limb Deformities • Curvature of the spine - Lordosis, - Kyphosis - Scoliosis

Osteogenesis Imperfecta- essentially BRITTLE BONES --bones break very easily so OTs work with children with ADLs/IADLs to perform in a safe way Arthrogryposis- essentially JOINT contractures due to the condition- muscle and bone Juvenile rheumatoid arthritis- a lot of adaptations- can be flare ups in the joints that cause a lot of pain and difficulty for child to put on and off their coats/shoes Congenital limb deformities- where you may see an amputation Curvature of the spine- kyphosis (humpback), scoliosis, lordosis

How common are ACE's?

Over 50% of the study population had ACEs so they are common!! How common are ACE ACEs are relatively common 41% of the population in the study had zero ACEs 24% had 1, 13% had 2, 8% had 3, 14% had 4 or more

Birth to three is from ages 0 to 3 provided through the county 3 years qualifies them for services through the school ***In Wisconsin, parents can request services without a MD referral

Parent and family involvement is huge in birth to three- attachment drives child development!!! - When a parent & child dyad don't mesh well, development suffers

Criterion Referenced Tests • Performance is compared with a particular criterion or level of performance of a certain skill. • The purpose is to determine what skills a child can or cannot accomplish, not to compare the child with his/her peers. • Administration and scoring may or may not be standardized. • Certain scales are both norm and criterion referenced.

Performs this skill confidently 100% of the time, 50% of the time, or not at all Not to compare child with peers, just taking a snapshot of this day, then do assessment in 6 months to see if they can accomplish more skills Can the child feed themselves? Not HOW they do it, just if they CAN Certain scales are both NORM and CRITERION referenced

Primary Coach Approach to Teaming practices Encompasses 3 areas - Natural learning environments - Primary coach teaming practices (primary service provider) - Coaching practices

Primary Coach Approach to Teaming practices Encompasses 3 areas - Natural learning environments- cannot do direct instruction with small children- infants sleep half the time- very little time in formal instruction, but spend a lot of awful time in daily routines (getting diaper changed, eating a meal, and playing with a sibling) - So routine-based intervention is really key- b/c infants spend most of the time in play anyway- so utilizing the child's natural environment - using play allows the child to be motivated anyway to engage in the activity - Primary coach teaming practices - Coaching practices

M-CHAT R/F- A disability-specific screening tool for Autism in toddlers - • Two-stage parent-report screening tool to assess risk of ASD (16-30 months)

Primary goal= maximize sensitivity- want to catch as many cases of ASD as we can - this comes with a HIGH FALSE positive rate Even though a child comes up as a positive screen, it doesn't mean the child will be diagnosed with ASD- this is not the point of the questionnaire- sometimes it means that these positive screens have something else going on developmentally that requires further examination A very high sensitivity rate (91%)

Observational Assessment in a pediatric eval ¡ Provide ecologically valid information about occupational performance. ¡ Descriptions of the elements of the activity. ¡ Client, parent, and other caregivers may be interviewed. ¡ Repeated observations in natural contexts. ¡ Leads to Activity and Observational Assessment

Provide ecologically valid info about what the child is doing- write down what is going on so you can say "that while the child was unable to sit still in their area, there were kids lying all over the place and it felt a little disorganized and expectations were not clearly provided" --Describe elements of activity - what were the steps of the activity A whole evaluation may take a number of weeks- may observe on the playground, in the classroom (billing varies for this) - may or may not bill for a parent phone call---never able to do a perfect evaluation (but get to understand which pieces are most important and prioritize these) ***Leads to activity and observational assessment - This becomes easier with practice

Questions to ask yourself while going through an evaluation ¡ What is the reason for referral to occupational therapy? ¡ What is the child's health and or educational history? ¡ What are the key stakeholders' priorities? ¡ What functional skills does the child need to engage in occupations? ¡ What is the child's chronological age? Where is this child developmentally? ¡ What are the requirements of the funding agency? ¡ What resources are available to you?

Questions to ask yourself before and when going through evaluation process! --What did the child have in the past that might affect them now? --You have the whole family as the stakeholders- so parents are more in charge of the decision-making here --Know chronological age but may need to figure out developmental age through this evaluation- The parents may want the child to be able to do something that is typically done at their chronological age 4-5 level, (ex. Tying their shoes) but they are not there developmentally- so we may decide on adaptations like Velcro or slip on shoes --Requirements of funding agency- funding agency will almost always cover OT evaluation but after that we need to prove that they need certain OT interventions

¡ Why is reliability and validity Important????

Reliable and valid assessments you know you can count on these assessments to be true for the child you are evaluating in the context they are evaluating in

The pediatric Evaluation Report • Background / Subjective information Results of Interviews and checklists • Objective information Results of Activity Analysis Evaluations/Test Results • Interpretation of Results (Assessment) • Plan Like the format of a SOAP Note

SOAP • Subjective (interview & checklist) • Objective • Assessment ("child is displaying handwriting skills 2 SD below kids of their age") • Plan • Terminology • Test description • Relevance • Observations during testing • Reporting scores • Report administration procedures • Professional assessment

How are ACE scores determined? • While you were growing up, during your first 18 years of life: • 1. Did a parent or other adult in the household often ... Swear at you, insult you, put you down, or humiliate you? or Act in a way that made you afraid that you might be physically hurt? Yes No If yes enter 1 ________ • 2. Did a parent or other adult in the household often ... Push, grab, slap, or throw something at you? or Ever hit you so hard that you had marks or were injured? Yes No If yes enter 1 ________ • 3. Did an adult or person at least 5 years older than you ever... Touch or fondle you or have you touch their body in a sexual way? or Try to or actually have oral, anal, or vaginal sex with you? Yes No If yes enter 1 ________ • 4. Did you often feel that ... No one in your family loved you or thought you were important or special? or Your family didn't look out for each other, feel close to each other, or support each other? Yes No If yes enter 1 ________ • 5. Did you often feel that ... You didn't have enough to eat, had to wear dirty clothes, and had no one to protect you? or Your parents were too drunk or high to take care of you or take you to the doctor if you needed it? Yes No If yes enter 1 ________ • 6. Were your parents ever separated or divorced? Yes No If yes enter 1 ________ • 7. Was your mother or stepmother: Often pushed, grabbed, slapped, or had something thrown at her? or Sometimes or often kicked, bitten, hit with a fist, or hit with something hard? or Ever repeatedly hit over at least a few minutes or threatened with a gun or knife? Yes No If yes enter 1 ________ • 8. Did you live with anyone who was a problem drinker or alcoholic or who used street drugs? Yes No If yes enter 1 ________ • 9. Was a household member depressed or mentally ill or did a household member attempt suicide? Yes No If yes enter 1 ________ • 10. Did a household member go to prison? Yes No If yes enter 1 _______

SUD or mental health disorder Separated parents or divorce is a risk factor for an ACE score With the pandemic, domestic violence is increasing--- wonder if ACE scores will increase b/c of the pandemic

In the AOTA practice framework there are PARALLELED co-occupations and SHARED co-occupations - 2 people sitting on a bus to a shared destination- since they are not INTERACTING this is NOT a co-occupation according to how Barnekow framed this Ex. Child playing (occupation) Mother cleaning and doing caregiving after child leaves Is NOT a co-occupation- b/c not temporally linked even though it is the same space

Say shared intentionality, physicality and emotionality need to be involved in co-occupation!!! Co-occupation occurs in the same space and are temporally linked!!!

How do birth to three develop outcomes and goals? After child becomes evaluated and is eligible for the program, the team establishes outcomes When a child has an intake, evaluation, then they have an IFSP meeting Interview family about their routines- routine-based interview Ex. SAFER Scale for Assessment of Family Enjoyment within Routines (SAFER)- a routines-based interview

Scale for Assessment of Family Enjoyment within Routines (SAFER)- a routines-based interview - This is a family assessment- to increase awareness of team and family - Want to use routine to help build skills SAFER provides a picture of what is occurring during routines - Provides a picture of what is happening - Through this- it lets mom know they are working hard to complete diaper changes - We would let mom know that we could help with this if she wants this to be an outcome - "Johnny will lie still, have eye contact with mom and hand mom the diaper before changing the diaper" - example outcome ***This is a very fluid process

Seizures and Epilepsy • Seizure: Temporary, involuntary change of state of consciousness, behavior, motor activity, sensation or automatic functions. • Epilepsy: Chronic neurologic condition of recurrent seizures that occur without the presence of other brain abnormalities.

See and treat children with seizures Epilepsy- chronic recurrent seizures WITHOUT presence of other brain abnormalities When seizures are severe, they do affect the person's cognitive ability

Self regulation and co-regulation - Self-regulation promotes wellbeing across the lifespan, including educational achievement and physical, emotional, social and economic health. Self-regulation can be defined as...

Self-regulation can be defined as the act of managing thoughts and feelings to enable goal-directed actions, and includes a variety of behaviors necessary for success in school, relationships, and the workplace Co-occupations help promote self-regulation Self-regulation is something we have to do across the lifespan Related to educational achievement People who can self-regulate as adults have better educational outcomes, social and economic health What we do with co-regulation is a contributing factor to self-regulation

Co-occupations help promote self-regulation

Self-regulation is something we have to do across the lifespan Related to educational achievement People who can self-regulate as adults have better educational outcomes, social and economic health What we do with co-regulation is a contributing factor to self-regulation

Co-regulation definition The supportive process between caring adults and children, youth, or young adults that fosters self-regulation development is called "co-regulation."

Self-regulation occurs from Co-regulation Co-regulation leads to self-regulation Co-regulation FOSTERS self-regulation See mirror neurons present at a very young age- this is the beginning of that co-regulation You can make a face at a baby and if they are given enough time, they will make that face back to the adult What we do with co-regulation is a contributing factor to self-regulation

Co-occupation occurs in the same space and are temporally linked!!!

Shared intentionality, physicality and emotionality need to be involved in co-occupation!!!

Aspects of Co-occupation-Assessment A big circle around all of these circles- signal that it is a co-occupation***

Shared physicality Shared emotionality Shared Intentionality There is conceptualized a fourth circle- shared communication

Co-occupation profile There is an occupational profile template but there is a need for a co-occupational profile template

So we can adapt what we are looking at - to look between caregivers and children Can ask questions about one's daily routine and get the caregiver's impression and see what is happening We are just barely scraping the surface on what current events mean for co-occupation (like COVID-19)

OT - Assessment Questions for the Occupational Profile - Tell me about satisfying daily routines that you and your baby engage in. • How do you and your baby have fun or enjoy each other? • Tell me about a routine that hasn't gone well or describe your daily routines (breakfast, lunch, nap time, dinner, bedtime). • What do you think contributed to the daily routine that hasn't gone so well? • Are you sleeping and eating well? • How would you describe your relationship with your baby?

Some questions you can add to the occupational profile if you suspect the parent is struggling with mental health challenges ***All about the caregiver AND child

Infant Mental Health Intervention • Videorecording - Co-occupational engagement & attachment • Ask caregiver how he/she feels as they observe play • Ask caregiver how the child may feel • Ask them to identify what went well and what didn't go so well. • Discuss toy use; environmental considerations (noise or distractions). • Identify aspects during the play where shared physicality, emotionality, intentionality and communication occurred.

Sometimes during the interaction it is hard to pick up that the child is getting fussy, a parent escalating and the child too Parent often doesn't understand the child getting frustrated

Neural Tube Defects • Encephalocele-brain protrusion through fissures in the cranium • Spina Bifida - Congenital defect of the vertebral arches and spinal column - Occulta - Spina Bifida with no pouch or sac - Cystica - With meningocele - Myelomeningocele- includes nerve roots in the pouch.

Spina bifida- congenital defect Seeing decrease in neural tube defects b/c of prenatal vitamins The roots in the most severe form can bulge out and see sac protruding from child's spine 3 types of spina bifida --occulta (less severe), cystica, myelomeningocele (most severe) Some use a walker with occulta or cystica, others use a wheelchair with myelomeningocele When spina bifida is noted during pregnancy, there are some surgical advances used to help decrease the effects of this problem

Structure of birth to three- natural environment through every step in birth to three process Step 1- Identification and referral- when marketing birth to three program- share information on natural environment and the emphasis on SUPPORTING parents

Structure of birth to three - Identification and referral- rely on physicians and parents and childcare providers to identify developmental issues/concerns- ANYONE can make referral to early intervention programs but parents need to consent to make anything go forward ***So if others make referrals on behalf on someone, they should call the parent

The Interview (surveillance) ¡ Surveillance is the systematic process of collecting information. ¡ Be aware of the child's response to adult discussions ¡ Interview others ¡ What is the family seeking from services? ¡ Determine expected outcomes ¡ Assure understanding ¡ Can be used to build rapport and validate information from other assessments

Surveillance (interview) is like a private detective to get info you need ---Assume that child understands what you are talking about when you are talking to parent ---Interview as many people as you can - child, teachers, doctors, anyone else involved with child ---What is the child expecting, what is the parent expecting ---Make sure the child is understanding what you are asking and what you are doing ---You are building rapport with child and family Need to weigh goals of parents and child differently ---Often start out with parent Then turn to child "It sounds like your mom is concerned with you not being able to tie your shoes, is that something you want to work on?" BUT NEED TO DEVELOP RAPPORT WITH CHILD FIRST - Child won't do something they don't want to do - Motivation is a huge way to make progress on goals

The primary standard scores used in standardized testing are the Z-score and the T-score. The Z-score is computed by subtracting the mean for the test from the individual's score and dividing it by the SD. The negative value of the first score indicates that the Z-score value is below the mean for the test, and the positive value of the second score indicates that the Z-score value is above the mean. ¡ T Scores ****(These are BELL CURVE SCORES)

T score is a conversion of raw data to the standard score when the conversion is based on the sample mean and sample standard deviation In a T-score distribution, the mean is 50 and the SD is 10. All T-scores have positive values, but because the mean of a T-score distribution is 50, any number less than 50 indicates a score below the mean. ***The T-score is derived from the Z-score

Conduit to LTSAE Target Audiences

Target audience= PARENTS But HCP can use materials and introduce them to parents CDC wants STATE systems of care to integrate them into practice --ex. Want WIC providers to include these during nutrition visits, and want physicians to incorporate during their work flow Want these systems of care to use materials Attempt to get state-wide integration--ACT EARLY AMBASSADORS Materials are very high quality Designed for parents Encouraging Can customize materials with your agency's logo

Technical Aspects ¡ Reliability The three forms of reliability most commonly used in pediatric standardized tests are (1) test-retest reliability, (2) interrater reliability, and (3) standard error of measurement (SEM). Test-Retest Reliability

Test-retest reliability is a measurement of the stability of a test over time. The correlation coefficient between the scores of the two test sessions is the measure of the test-retest reliability.

2 Baby demonstrating the asymmetrical tonic neck reflex (ATNR) reflex. The turn of the infant's head automatically elicits flexion of upper extremity behind the head and extension of lower extremity.

The ATNR is meant as a reflexive, protective response an infant makes when turning head toward a auditory or visual stimulus in the environment.

The three forms of reliability most commonly used in pediatric standardized tests are (1) test-retest reliability, (2) interrater reliability, and (3) standard error of measurement (SEM). SEM

The SEM is a statistic used to calculate the expected range of error for the test score of an individual. It is based on the range of scores an individual might obtain if the same test were administered several times simultaneously, with no practice or fatigue effects The SEM creates a normal curve for the individual's test scores, with the obtained score in the middle of the distribution Generally, test manuals report the 95% confidence interval. As can be seen by the preceding equation, when the SD of the test is high, or the reliability is low, the SEM increases.

Hierarchic ranking- Not the higher score is the better - Percentile - Age equivalent age-equivalent score

The age-equivalent score is the age at which the raw score is at the 50th percentile. The age-equivalent score generally is expressed in years and months, e.g., 4-3 (i.e., 4 years 3 months). It is a score that is easily understood by parents and caregivers who may not be familiar with testing concepts or terminology Age equivalents, then, are a type of standard score that can contribute to an understanding of a child's performance, but they are the least psychometrically sound, can be misleading, and should be used only with caution

What do these ACE scores mean? • Generally speaking the higher the score the greater the risk for poor health outcomes. • It only looks at ONE risk factor for chronic disease and does not take genetics or other factors into account. • The ACE quiz does not assess factors relating to resiliency - Nurturing and responsive care - Warm loving relationship

The higher the ACE score, the greater the risk for poor health outcomes Limitation of ACE - does not take genetics into account - ACE score does not assess factors relating to resiliency- even though children have ACEs, if a child has one person in their life that is a protective factor (warm loving and nurturing) this can promote resiliency ***OUR ROLE is to promote resiliency by supporting caregivers- it also may be the case that we are that one nurturing person too

Hierarchic ranking- Not the higher score is the better - Percentile - Age equivalent percentile score

The percentile score is the percentage of people in a standardization sample whose score is at or below a raw score

Types of Scores Standard Scores (Think Bell Curve) Standard Scores

The range for when children start to DO WHAT is the biggest for any milestone

The range for when children start to WALK is the biggest for any milestone (creeping, reaching, grasping, sitting) Each has its own expected age it should be achieved Anywhere from 9 to 18 months walking is expected!!

Autism Spectrum and Related Conditions • Autism Spectrum Disorders - Deficits in social communication • Deficits in social reciprocity • Deficits in nonverbal communication • Deficits in developing and maintaining relationships - Deficits in restricted, repetitive behaviors, interests, or activities • Stereotyped, repetitive movements, object use, and speech • Rigid, insistence on sameness in routines or rituals (behavior or nonverbal behavior • Restricted, fixated interests • Over- or underactive to sensory input or unusual interest in sensory components of environment

There are 2 primary characteristics- deficits in social communication (reciprocity, nonverbal communication, developing and maintaining relationships) OTs can help with autism diagnostic behavior schedules- is a consensus scoring system Child may not respond to invitation to play Look for cues in nonverbal communication- gestures, pointing to an object Look at affect and reciprocity- is the child having fun and experiencing enjoyment Will often wait and look for how the child asks for more (do they ask, pull on the person's arm)- indicators of social communication problems - some kids won't even try Can see deficits in developing and maintaining relationships- have a hard time understanding social cues- but do want to be in relationships Restricted repetitive behaviors interests or activities There is a gaze where the child looks to the side Some hand posturing May have repetitive use of tools or toys even though they are shown different ways of using a toy- can become distraught when pushed to play with truck differently Insistence on routine and ritual- change can be distressing Restricted or fixated interests- like in dinosaurs or a certain doll See over- or underactive to sensory input- unusual interest in sensory components of the environment—ex. A helicopter's wings that are spinning or really like high-pitched noise

Are there infant mental health disorders? • DSM -V • Zero to Three System: DC:0-5

There are actually infant mental health disorders- they are listed in DSM-V and zero to three system: DC 0-5 Sensory dysfunction sensory modulation and processing disorders are part of the DC 0-5, where they didn't make it into the DSM-V We can offend parents if it is not approached in a thoughtful way (need to draw from PAUSE approach or the FAN model)

The relationship between occupational engagement and health Infancy • Co-occupational engagement • Occupational engagement Early childhood- adult • Overall health and well-being Depicting that in infancy, a large amount of time is spent in CO-OCCUPATIONAL engagement

There are times when infants are engaged in occupations - maybe when they are sleeping But in comparison to older adults and even middle childhood, the co-occupation is a bigger part of toddler and infancy Co-occupation supports occupational engagement later on and leads to overall health and well-being

Birth to three really went through a paradigm shift

There has been a shift to provide birth-3 in naturalistic settings - Working with kids in their homes with parents and families Relationship-based program- trying to increase child participation in natural environments - Focus on child and family strengths and using a coaching approach Birth to 3 is a federal and state mandate- comes from IDEA - This is part C of IDEA

Levels of adaptive functioning - caregiving environment Model of Co-occupation Shared physicality, emotionality, intentionality, communication These are the levels of caregiving environment (well adapted to good enough, strained, compromised, disordered)

These are the levels of caregiving environment (well adapted to good enough, strained, compromised, disordered) --well adapted to good enough--Does parent --strained--child relationship have ups and downs but conflicts resolved --compromised--Some adaptive qualities but controversy apparent --disordered--Level IV is where CPS should be called (based on DC 0-5)

Norm Referenced Tests • Large diverse population. • Norm or average is derived from scores. • Performance is compared with a normal sample. • One or more areas of behavior. • Materials and activities are familiar and typical for children of the age group. • Strict standardized protocols for administration and scoring.

This is super important You have a large population it was normed on Get an average of the large population Person is compared to the large normative sample Materials and activities are familiar for kids of this age group (ex. Peabody motor skills has a buttoning area- kids these days are not always familiar with buttoning) (or kids who've never been in preschool may have never been exposed to scissors) Still have to score them according to directions, even though the child doesn't do it even when you saw them do it before (this is all baked into the norms)

Learn the Signs. Act Early. MATERIALS

This slide shows examples of the different types of materials that are available through the CDC. PDF files for print copies of the materials including brochures, growth charts and books are available on the CDC LTSAE website. ***As an Act Early Ambassador, my role is to help interested parties locate this resource.

ASQ-3 screening tool - Increases everyone's self-awareness about where a child lies developmentally

Upon this screening, a child may be identified to need OT evaluation - raises awareness of who we should use from the EI team to conduct possible evaluation

Theories Summary • Occupational therapists use a variety of theories that originated from other disciplines. • Models of occupational therapy practice examine the complexity of human occupation and consider the person, the environment, and the tasks to be completed. • Current ideas about occupational performance embrace dynamic systems theories. • Therapists may use a model of practice as well as multiple frames of reference. • Therapists must use evidence-based practice when selecting frames of reference for assessment and intervention.

Use a variety of theories and those from other disciplines Attachment theory Using theory and FOR helps us be Evidence-based practitioners

CDC's Milestone Tracker App In the Checklist tab, the CDC includes a description of the milestone, and there are videos of the behavior included in many of the milestones. Parents then can check a box that is consistent with their observations.

Videos are really helpful Also an equity issue- But if we are talking about disparities, then it means people with those devices can get videos and those without devices cannot • Recognize strengths and areas of concern • May be time to talk to a doctor and share her milestone summary After you complete the milestone checklist, you will then be directed to the "When to Act Early" section. This section is tailored to the child's age and any concerns the parent may have. If the parent selects any of the items on the 'When to Act Early' tab, it is important that they act early and talk to the child's doctor about the missed milestones or any concerns they may have with the way the child plays, learns, speaks, acts, and moves. As you likely noticed, the App prompts you throughout.

Relation-based assessment and intervention - How does the parent feel about receiving services for their child? - What type of relationship does the parent want to have with the provider? - What are the primary caregiver's priorities? - Who is leading the therapy process? • Family-centered care

We ask parents how do they feel about receiving services for their child Parents didn't invite us OTs into their lives What type of a relationship does a parent want with a provider Ask how would they like to be addressed- it's about developing that relationship Need to ask the parent's priorities

- First time mother, white, brought child for a 6 month developmental screening - Reports difficulty concentrating at simple tasks struggles feeding her baby and WIC appointments - Her and Samuel watch TV till 2-3 am She says "I feel fine" Mother is slow to respond to Samuel, or looks at Samuel with a flat affect - Like in flat affect paradigm- he stops interacting Her immediate family is out of state- husband works constantly "Never knew mother was so hard"

What are Mrs. R's strengths? - Making an effort to take son to clinic for 6 month developmental eval - She dresses him and bathes him - Has understanding of fussy response - Hard working and strong willed (subjective) - Mother is 29 years old (not too old, not too young) - White privilege - Taking care of the child on her own without a support system ***Important to always start with strengths- using a strength-based approach I helpful for everyone Given what we learned about maternal mental health disorders, what would you like to explore further in regards to Mrs. R's behavior? (PPD, PTSD, substance use disorder) - Mrs. R's behavior: · PPD, lacking social supports difficulty concentrating, exhausted, no appetite, sleep difficulties (sleep is a meaningful occupation and should be one we attend to) "never knew mothering would be so hard", she does not mirror his emotions etc assess social context and supports to see what would help her have more support ---observe interaction with the child and how that's affecting the relationship of the child - co-occupation What would you explore further in regards to Samuel's behavior? - Evaluate sensory processing more - Observe daily routines and sensory responses to that - His sleeping patterns - Ability to self-regulate and self-soothe --Where is Samuel's overall development at? - Was he born pre-term at term? What theories or conceptual practice models may inform your thinking? - Co-occupation, attachment - PAUSE approach, IRM - to try and listen and understand - PEOP, MOHO, CMOP-E - Developmental - Social learning - Possible CBT approach that would benefit Mrs. R and Daniel

Adjusted age is 8 months, 3 weeks- born premature at 29 weeks Maternal mental health - Single mom - Gave birth at 17 years - Reminder of experience in the hospital, doesn't take Anna to hospital appointments (PTSD!!!- affects caring for Anna) - Unable to sleep at night, startles Scheduled frequent and several visits with OT - Ms. L cancelled all visits - Agrees she will be available for the next OT visit Unable to roll from stomach to her back OT would usually conduct a more thorough evaluation to determine eligibility for services

What are Ms. L's strengths? - Her support system - having her mother take daughter to doctor appointments - Young enough to work technology (could use Milestones app) - Still wants to plan birthday party - Understands importance of keeping child eligible for OT Ask more questions about interests with daughters, what resources she has, if she finished school? Other supports? Use Pause Framework to pause and understand the family situation - Looking at the strengths of the family and what they have to offer is so important b/c this is what can help us work through some of that frustration - And working with a reflective supervisor about the family not showing up Given what we learned about maternal mental health disorders, what would you like to explore further in regards to Ms L's behavior? - PTSD!!!- affects caring for Anna (hyperarousal and PTSD) - May be trying to avoid conversations (as seen in her texting during the session) - Maternal PPD (trouble sleeping, feeling exhausted all the time) Do a co-occupational profile - How does mother feel about observing her play - Is there a lack of education on parenting What would you explore further in regards to Anna's behavior? - Missing milestones - Developmental screening set this up What kind of attachment relationship does the baby and mother have? What theories or conceptual practice models may inform your thinking? - Developmental theories - Milestone moments - PAUSE theory- b/c there is so much unknown - IRM- empathize first - b/c probably still a lot of fear (PTSD and PPD) - Co-occupation

Assessment - Develop an understanding of the co-occupations that are important to the family - Observe them engaging in the co-occupations - Identify aspects of co-occupational performance that may be interfering with engagement - Identify the impairments influencing engagement

What are those daily activities that are important to the family? Want to observe family engaged in co-occupation ---Teletherapy has allowed OT to do this- we can still continue observing parents engaged in co-occupation Sometimes you may be observing a child with learning processing difficulties so they may need space and time w/n the interaction to react - Mom may need to wait and smile at baby and give baby time to process info before responding - Telling mom to read baby's cues can be helpful

What are Adverse Childhood Experiences? • Traumatic experiences • Place child at risk for developmental, behavioral and chronic conditions • Affect well-being and longevity • Are preventable but somewhat common • Effects are cumulative with a "graded dose-response"

What is trauma "exposure to actual or threatened death, serious injury, or sexual violence..." (American Psychiatric Association, 2013, p. 261) Adverse Childhood Experiences or ACES are traumatic experiences and places them at risk for developmental, behavioral, and chronic conditions Preventable yet common

The OT Process in infant mental health practice • Assess • Intervene- consider the interprofessional team. - Refer to social services • Discharge

What's the process We as OTs assess --can do screenings --observe Intervene --may refer to social services discharge

PAUSE • Perceive - observe and listen • Ask questions to learn more about what is happening • Understand each participant's experience or viewpoint • Strategize - select and take actions • Evaluate the outcomes using reflective processes (Tomlin & Viehweg, 2016)

When we are in a situation where a parent is saying this is hard work and I rarely experience joy we need to observe and listen Story will unfold when we stop and listen Respect experiences and viewpoint of the parent Strategize- told her about resources Evaluate the outcomes - see what's happening- what was the outcome using reflective process

Getting Started with standardized assessments ¡ Read the test manual. ¡ Understand the purpose and intent of the test. ¡ Practice the procedures. ¡ Learn the scoring process. ¡ Understand how to interpret the test results. ¡ Review research of the validity and usefulness of the instrument

When you are giving a standardized assessment READ the manual and practice giving it!! Understand scoring Research validity and reliability

Interpretation ¡ Test Score Interpretation § Performance = Typical Performance? § Performance = Teacher/Parent Report § Complete? § Any changes to standardized administration? **These are the things you take into consideration when you look at the scores of a standardized assessment tool and you are writing the report

When you interpret the scores of the assessment, you can know was that typical performance of the child? If you don't know if this was typical ask the parent - you note this when you interpret test scores Complete- Did you complete the assessment? Any changes to standardized administration- then you can't say the scores are 100% reliable and valid

Observation in a pediatric eval ---activity analysis and ecological assessments

Where you get the whole piece of activity analysis and ecological assessment

Aspects of Co-occupation-Assessment Women quilting

Women quilting--Rated this as a more complex co-occupation A big circle around all of these circles- signal that it is a co-occupation*** See levels of complexity in the co-occupation itself More complicated b/c making quilt together, one is reaching across another (physical reciprocity), shared emotionality, and the goal setting to pull this co-occupation off and have it occur is pretty complex

Empowering Families Parents sometimes report that their child's doctor was not responsive to their concerns about the child's development or suggested a "wait and see" approach that the family is feeling uneasy about. You can help support parents in getting their concerns addressed with a few reminders:

You can help support parents in getting their concerns addressed with a few reminders: - Acting early on concerns is the best way to help their child and they are doing the right thing. - They know their child better than anyone. - Families do not need a referral to contact EI services (under age 3) or their local public school (age 3 and over) to find out if their child might be eligible. App has video recordings- designed to be parent friendly

Rating Scales (part of interview in a peds eval) ¡ Inventories and checklists ¡ Can provide qualitative or quantitative information about child development, child-caregiver interactions or the child's environment

You want a nice broad understanding of what is the situation with the child

Z score is a conversion of raw data to a standard score, when the conversion is based on the population mean and population standard deviation - t- score and z-score has middle scores of bell curve - what is WNL and what constitutes something outside of typical Generally, a Z-score value of −1.5 or less is considered indicative of delay or deficit in the area measured, although this can vary, depending on the test.

Which of the following statements best describes the benefit of using an occupation-centered practice model? a) Addresses the unique value of occupation b) Provides intervention protocols c) Provides specific intervention activities d) Addresses child's limitations in skills

a) Addresses the unique value of occupation

What type of play involves looking and touching the mother's face, putting hands in one's mouth and responding to familiar people? a) Exploratory b) functional or relational c) pretend d) symbolic or imaginary

a) Exploratory

Why should an occupational therapist take time to get to know the things a family does together, their weekly routine, and an explanation of family membership? a) Involvement in family is central to best practice. b) It is not needed, but it is nice to do. c) To complete demographic information for insurance purposes. d) To determine if they have values of which the practitioner agrees.

a) Involvement in family is central to best practice.

Which frame of reference emphasizes techniques to teach children movement that resemble coaching? a) Motor control/motor learning b) Rehabilitation c) Biomechanical d) Ayres' sensory integration

a) Motor control/motor learning

How do models of practice help therapists engage in sound therapeutic reasoning? a) They provide structure to guide thinking. b) They address theory but not practice. c) They predict the outcome of intervention. d) They examine physical characteristics of child.

a) They provide structure to guide thinking.

Which type of parenting style is associated with children who rank higher on many measures of social and cognitive development? a) Warm, responsive, positive b) Neutral, rigid, critical c) Absent, unstructured, negative d) Cold, neglectful, negative

a) Warm, responsive, positive

Approaches to Self-Reflective Practice and Interventions • Is at the core of practice - Reflective supervision - infant mental health endorsement - Self awareness - journaling - PAUSE Framework (Tomlin & Viewheg) - Intentional Relationship Model (Taylor, 2008)

as an infant mental health provider - has a reflective supervisor she would meet with monthly Talk about triggers and process them Infant mental health endorsement is another way we can develop self-reflective practice Need to be aware of emotions and process them- can do this through self-awareness and journaling

What is the recommended sleep for 14 to 17 year olds? a) 14 to 17 hours b) 8 to 10 hours c) 12 to 15 hours d) 9 to 11 hours

b) 8 to 10 hours

Which frame of reference provides an environment in which the child decides to select activities that require responses to movement, balance, weight bearing, and tactile activities? a) Motor control/motor learning b) Ayres' sensory integration c) Neurodevelopmental treatment d) Developmental

b) Ayres' sensory integration

What is the last step in interpersonal reasoning? a) Choose a response mode or mode sequence b) Gather feedback c) Anticipate d) Determine if a mode shift is required

b) Gather feedback

Which model of practice emphasizes the child's subjective experience of his/her abilities? a) Occupational Adaptation b) Model of Human Occupation c) Person-Environment-Occupation-Performance Model d) Canadian Model of Occupational Performance and Engagement

b) Model of Human Occupation

Which principle does not follow neuromaturational theory? a) The sequence and rate of motor development are consistent among infants. b) Movement emerges from an interaction and cooperation from many systems. c) Movement progresses from primitive reflexes to voluntary control. d) Low-level skills are pre-requisites for certain high-level skills.

b) Movement emerges from an interaction and cooperation from many systems.

Which stage of motor learning is illustrated as the toddler attempts to place a shape into a container multiple times using an effective reach and grasp pattern often, but making errors? a) Skill achievement b) Perceptual learning c) Functional performance d) Exploratory activity

b) Perceptual learning

Which of the following is not considered a part of body language? a) Mannerisms b) Speech c) Posture d) Position

b) Speech

Kasey, the occupational therapist, meets with the principal of the school to see if it is possible to change the cafeteria to better accommodate to her client who has difficulty eating in the noisy and distracting cafeteria. She brings in stories, research and ideas of how to rearrange things to better meet the child's needs. What type of mode best describes Kasey's approach? a) Collaborating b) Instructing c) Advocating d) Encouraging

c) Advocating

Which of the following is not an occupation-centered model of practice? a) Canadian Model of Occupational Performance and Engagement b) Person-environment-occupation-participation c) Biomechanical approach d) Model of Human Occupation

c) Biomechanical approach

Mary (the OT) is excited to work with the family of a friend with whom she has lost contact. Mary hopes the family will be able to connect her with her friend and is looking forward to hearing about her friend. St the next session, she asks the mother many questions about her friend and they spend a lot of time discussing their home town, etc. Which statement describes this scenario? a) It is not therapeutic: The relationship serves no purpose. b) It is therapeutic: Therapist, child and family have a reciprocal caring relationship. c) It is not therapeutic: Mary is benefiting, but not the child and family. d) It is therapeutic: Both parties are benefiting in the relationship.

c) It is not therapeutic: Mary is benefiting, but not the child and family.

How should therapists communicate with parents and family? a) Share information with both parents to lessen the stress on just one parent. b) Share information with one parent to assure that it is accurate. c) Share information with everyone who comes in contact with the child (family or not). d) Only include information in writing to be sure you communicated clearly.

c) Share information with everyone who comes in contact with the child (family or not).

Which approach is best when developing a home program regarding self-care? a) Require parent repeat new steps on a routine basis and document progress. b) Add new home programs each week with clear instructions for parent to complete the assignments. c) List all the steps and without practicing it, require the parent teach it to the child. d) At the request of the parent, practice the new steps until the child is ready to carryover at home.

d) At the request of the parent, practice the new steps until the child is ready to carryover at home.

Ava is a 6 year old girl with spina bifida who is generally happy to be at occupational therapy. On this day, she comes to therapy looking sad and tearful. She tells the therapist that she had a fight with her best friend at recess. What type of characteristic is described in this scenario? a) Mode change b) Social c) Enduring d) Situational

d) Situational

Which statement best reflects how occupational therapists work with children with disabilities and their families? a) Therapy is based upon the child and family needs; the therapist must adapt to meet their needs. b) Recommendations are based upon the therapist's expertise; parents must make every effort to meet the recommendations. c) The primary client is the child or youth; the therapists focuses on the client's needs. d) Therapy is based upon the child and family system; the therapist helps the child engage in the family occupations.

d) Therapy is based upon the child and family system; the therapist helps the child engage in the family occupations.

Outcome of screening vs. outcome of evaluation

outcome of screening-Refer family to appropriate services outcome of evaluation-not just referring, Part of bigger diagnostic team, and say if the child is eligible for OT and how much of it

Shared physicality Shared emotionality Shared Intentionality There is conceptualized a fourth circle-

shared communication

PCATT used in birth to 3 in Wisconsin= what is this?

the primary service provider (PSP) approach to teaming is a family-centered process for supporting families with young children with disabilities in which one member of an identified multidisciplinary team is selected as the PSP who receives coaching from other team members and uses coaching as the key intervention strategy to build capacity of parents and other care providers to use everyday learning opportunities to promote child development PCATT is an example of an EBP model

Various types of seizures exist o Generalized --Absence --Myoclonic --Akinetic --Tonic-clonic o Partial --Complex-partial --Simple - partial --Infantile spasms o Mixed • Treatment ---medication, ---Controversial diets (ketogenic) ---surgical interventions

types of seizures- parents are trying to capture their child and use it as documentation for doctor ---absence- ---myoclonic ----akinetic ----tonic-clonic Can have partial seizure disorder AND mixed As an OT medical educational professional - you should make parents aware of potential ABSENCE seizures like when a child is checking out more than once or twice The child may not seize in a doctor visit so its really important to make note with a video what is occurring There are medications and diets given (controversial) Surgical interventions inserted in brain to disrupt electrical connection causing seizure

Evaluator responsibilities for standardized assessments

¡ Item administration ¡ Interpretation of results ¡ Reporting results ¡ Application of results You are responsible for these

Common Ground in all Peds Settings

¨ Referral ¨ Screening ¨ Evaluation ¨ Treatment Plan (multiple models of service delivery) ¨ Coordination of Services ¨ Follow-up plans ¨ Discharge or dismissal of services

Frames of Reference

• "A set of interrelated internally consistent concepts, definitions and postulates that provide a systematic description of and prescription for a practitioner's interaction within a particular aspect of a profession's domain of concern" (Mosey, 1981, p. 129). • Provide occupational therapists with specific strategies and techniques based on theoretical principles. • Are lenses or ways of viewing a child's/family's behavior or performance.

Theory

• A "plausible or scientifically acceptable general principle or body of principles offered to explain phenomena" (Merriam Webster, nd). • Explanation of observed behaviors that is based in data. • Describe fundamental principles and create an abstract language system for a profession.

Models

• A pictorial representation that expresses observations and data about certain portions of a theory. • Are often used to test theories. • If a model is accurate, it will allow predictions with actual data.

Foundational Theories • Developmental Theories • Piaget and cognitive development

• Adaptation: The child's ability to adjust to change to fit into the environment • Schema: How children represent objects, events, and relationships • Assimilation: Incorporating new knowledge into existing cognitive structures • Accommodation: New learning, adapting cognitive structure to new information Piaget developed his theories based on watching his own children learn This is how he framed how children learn things

Rehabilitative FOR

• Allows a child or youth to engage in desired occupations with compensations and adaptations • Providing adaptive equipment or modifications • Providing appropriate assistive technology • Requires a thorough analysis of the activity

Neurodevelopmental (NDT) FOR

• Analyze missing or atypical movement patterns. • Use therapeutic handling to facilitate postural control and movement synergies. • Inhibit or constrain abnormal movement patterns. • Focus on changing movement patterns. • Child is active participant. • Therapists emphasize quality of movement. Using therapeutic handling to promote movement patterns that will help child grow motorically Basis of NDT is that through handling, the therapist facilitates motor development Want child to be active Looking at QUALITY OF MOVEMENT here Could put hand on shoulder/hip or distally hand/fingers to facilitate movement

Biomechanical FOR

• Based on kinesiology and physics. • Require the understanding of anatomy and physiology related to posture and movement. • Movement occurs against gravity and pressure. • Limb movement requires postural adjustments to allow individuals to remain upright against gravity. • Optimize alignment as basis for movement and control of extremities. • Methods include range of motion, strengthening, positioning, and modification. This is like physical rehabilitation course May do splinting, strengthening May look at child performance from biomech FOR

Sensory Integration FOR

• Based on neuroscience. • Children receive, perceive, interpret, and react to sensations, and use sensory information to produce adaptive behaviors in response to environmental demands. • With sensory integration and experiences of success, development occurs, enhancing neuroplasticity. • Sensory input can be incorporated into activities systematically to elicit an adaptive response. • Must be active, child-directed. More of a playful, child-directed approach Help the child integrate sensations in response to environmental demands

Cognitive Behavioral FOR

• Based on the idea that problem behaviors are caused by beliefs or thoughts (cognition) • Change the thoughts, change the behavior • Uses positive self-talk and feedback for successes Focus on changing THOUGHTS so you can change behavior Want to use positive self talk for success

Developmental FOR

• Based on the ideas and knowledge about the typical progression of developmental skills by age • Predicts skills will become more complex and more competent over time • Suggests a temporal sequence during which specific skills should be expected • Suggests intervention to generate the "next" skill • Based on older linear vs systems ideas about maturation Somewhat linear Will learn about the CDC's milestone moments Help family engaged developmental monitoring from a developmental frame of reference While developmental FOR are based on older linear models- these still help us understand if kids are meeting milestones- helps with Peabody scale b/c built upon developmental FOR These qualify kids for services often times Even though linear in its perspective So we want them to move from rolling to be able to transition to side sitting then to 4 point ---all point to this developmental FOR

Cognitive FOR

• Based on the work on self-efficacy • Use a problem-solving approach to work toward child-derived goals through careful questioning rather than instructing • Steps include • Task analysis • Anticipation of the child's difficulties • Exploration and selection of task-specific strategies • Application of a strategy to the task • Evaluation of strategies Using a problem-solving approach Using child's ability to problem-solve and help See this with SHOE -TYING Want to improve child's confidence and self-efficacy with this

Cerebral Palsy - Definition - Characteristics - Primary and secondary causes of CP

• Cerebral palsy- an event that occurs in the perinatal period • Can occur while the mom is carrying the baby- an event during the birthing process and shortly after (could be loss of oxygen, infection, premature birth, or some other effect that actually creates brain damage) • During the PERINATAL period- during pregnancy, during delivery or shortly after birth • Largely characterized by MOTOR deficits but b/c it involves a brain injury, it is likely children with CP have other problems—sensory, cognitive, and speech/language problems ON TOP OF MOTOR DYSFUNCTION • They are developing drugs if moms go into preterm labor that decrease likelihood of CP

Learning Theories • Social Cognitive Theories

• Children can learn by observing the behavior of others. • Children determine their own learning by seeking certain experiences. • Children learn indirectly by observing how their peers' behaviors are rewarded or punished. • Children learn social skills through group experiences. Children learn by observing - this is where the debate comes about violent video games

Foundational Theories • Developmental Theories • Vygotsky and the Zone of Proximal Development

• Cognitive processing is a social process. • Learning is critically dependent on social interaction • Zone of proximal development: The distance between the child's actual developmental level when acting independently and the level of potential development when supported by an adult. • Scaffolding: The process by which therapists support or guide a child's actions to improve competence. Vygotsky - cognition is dependent upon social interaction Zone of proximal development- distance b/w child independent work and adult support Scaffolding how we as therapists support/improve competence How is the OT scaffolding the child's work to achieve optimal outcomes

Detail of Pediatric Evaluation Report • Referral source and information (e.g., date of and reason for referral). • Relevant client information (e.g., name, identification number, medical history, and/or diagnosis, if applicable). • Description of the client's occupational profile. • Description of the process and assessment tools used to complete the analysis of occupational performance. • Summary of the findings from the assessment process and tools (e.g., assessment scores).

• Description of the occupational therapist's interpretation (e.g., judgment about how specific performance skills, performance patterns, contexts/environments, client factors, and activity demands influence occupational performance and participation and is related to the client's occupational profile). • Recommendations (e.g., whether or not occupational therapy services are needed; need for assistive technology or accommodations or modifications). • Occupational therapist's signature (e.g., first and last name)

Models of Practice • Systems approach: Importance of context in assessment and intervention

• Develop a picture or profile of the child's performance. • Focus on the interaction of person, environment, and occupation. • Focus on changing the child, task, or environment. • Modify the task or environment to improve the child's skills. • Increase the child's engagement by using activities that are meaningful. Concerned about interaction

Commonly Used Frames of Reference

• Developmental • Biomechanical • Motor learning • Rehabilitation • Neurodevelopmental • Sensory integration • Behavioral • Cognitive • Cognitive-behavioral

Foundational Theories • Learning and Systems Theories • Behavioral theories

• Instrumental or operant learning • Applied behavioral interventions • Shaping • Incidental teaching • Pivotal response May be token economies being used- these are based on operant conditioning Pivotal response used in kids w/autism

Motor Control/Learning FOR

• Motor control = directing/regulating movement. • Motor learning = ways of learning movements. • Problem-solving method, helping child find the best ways to move to solve a motor problem. • Analyze movement synergies. • Consider child's stage of learning. • Provide feedback to improve efficiency. • Provide opportunities for practice. • Promote independence and generalization. Motor control - direct/regulate movement Motor learning- Knowledge of results, knowledge of performance

Learning Theories • Dynamic Systems Theory

• Performance depends on • interactions of the child's inherent and emerging skills. • characteristics of the desired tasks or activity. • the environment. • Self-organization is optimal if the task has a goal and outcome. Maybe performance is not a linear trajectory Reliant on emergent skills and environment Not just motor skills- cognition, emotion Performance is multi-factorial Development is not linear

Foundational Theories • Maslow's Hierarchy of Basic Needs

• Physiological needs • Need for safety • Need for love and belonging • Need for a sense of self-esteem • Need for self-actualization Maslow- needs for safety help develop self-actualization Have to think about the basic needs of children and families we are serving Are they laid off, have food insecurity? Do they live in dangerous environments like cities with riots?

Models of Occupational Therapy Practice

• Provide structure to guide the process of clinical reasoning. • The practical expression of theory • Provides therapists with specific methods and guidelines for occupational therapy intervention • Promote the use of occupation centered practice and a broad scope of practice.

MCHAT-R: Administration • Two-stages:

• Stage 1: Parent completed questionnaire • Stage 2: Follow-up Interview (if positive screen) Response is yes or no MCHAT-R/F: Stage 2-Follow-Up Interview • General considerations: • If a parent reports "Maybe", ask whether most often the answer is Yes or No • In places where there is room to report an "Other" option, the interviewer must use their judgment whether the item is a Pass or Fail

Cognitive • Example: Cognitive orientation to daily occupational performance (CO-OP)

• Steps: • Focus on the occupations the child selects. • Use a general problem solving framework. • Use process questions to increase the child's awareness of the use of strategies. • Plan for transfer and generalization of the strategies. Child helps developing problem-solving framework

Self-Efficacy

• The influence of motivation and self-efficacy on learning. • If children experience success, they are more likely to seek additional challenges. • Self-efficacy beliefs determine • the goals that people set for themselves. • how much effort they expend. • how long they persevere in the face of difficulties. • how they respond to failure. These have been integrated into MOHO!! Kids begin to believe they are effective and able to do what is expected of them How do we as OTs help kids experience success? Do we adapt the task/environment or adjust their development

Calculating Adjusted Age (AA)

• Used for children who were born prematurely to "correct" the number of weeks they were born prior to their due date • It is the difference between the child's GA at birth and 40 weeks. • Children born at 36-38 weeks are often not considered premature. • AA usually used for the first 2 years of life - use the AA to compare with assessment scores.

ASQ - general developmental screening tool - looks at all different areas of development as a whole - not specific disabilities

•Used to accurately identify children who may be at risk for developmental delays •"Anytime" screening—expanded administration windows so the intervals are seamless from 1 through 66 months - Covers a BROAD range of ages (1 to 5.5 years) Visually this tells you already what is happening - Whether or not the child needs to be referred for a more formal evaluation or whether things are going well and no other action is needed If one or more scores fall in the black zone- need to be referred for further evaluation Gray area= want to keep watch of the child- invite family back in for another screener in the next few months White area= no concerns about where the child is now

Models of Practice

● An example of a model ● PEO Model Ø Person Ø Environment Ø Occupation

Foundational Theories Used in Occupational Therapy

● Developmental theories ● Learning and system theories

Peds, Fine Motor: Letter Formation with Playdough Child opened playdough container and form playdough letters (R, K, B) out of playdough snakes. Therapist is modeling and making suggestions for opening container and making snakes. At the end, the child was engaged in the activity in her own way and made a playdough mountain ● Identify an approach being used by the therapist ● Critique the session and identify additional activities or approaches the therapist could use.

● Identify an approach being used by the therapist ○ Developmental, Motor control/learning, and cognitive approaches were used in this video. ● Defend why the group chose the approach ○ Progression of developmental skills by age (less fine motor than using a pencil). Skills can become more complex over time (adjustment of required FM skills). OT was directing and regulating the child's movement. Allowed for problem solving.Consider child's stage of learning.Task analysis was completed and gave choices. Applied a strategy to the task. ● Critique the session and identify additional activities or approaches the therapist could use. ○ Adapting to what the child wanted to do: flatten the playdough and drag finger through it to make letters ○ Changing to material or medium to adjust difficulty

Peds, Mat Activity: Sit to Quadruped OT physically handles client to move into and maintain 4 point weight-bearing and transition back to sitting on mat ● Identify an approach being used by the therapist ● Critique the session and identify additional activities or approaches the therapist could use.

● Identify an approach being used by the therapist ○ NDT ○ Motor learning ● Defend why the group chose the approach ○ NDT: Therapeutic handling to facilitate postural control, child is active participant ○ Motor learning: gave feedback on how the child was performing, independence on exploring synergies ● Critique the session and identify additional activities or approaches the therapist could use. ○ Less physical handling ○ Place child in front of a mirror ○ Use different setting & environmental supports (not mat) ○ Add motor control: more environmental aspects to reinforce positive behaviors ○ Possibly incorporate behavioral aspects: Modeling & observation (of parent, sibling) ○ Continue giving feedback/reinforce confidence (cognitive)

Peds, Sensory Integration/Sensory Processing: Scooterboard & Letter Recognition Activity ○ 6 y/o rides scooter board down ramp into "sea" of pillows and finds 3 letters, then 2 letters and 2 numbers when instructed to find 4 letters and then successfully finds B & K letters, then M, Y & E ■ therapist uses direct verbal prompts (commands) and visual prompts (pointing) to guide child in play activity ■ therapist targeted cognitive, sensory and motor domains in one activity; integrated play... ■ Child must use scanning to find letters, arm/core strength to grab pillows, go down and pull up slide ● Identify an approach being used by the therapist ● Critique the session and identify additional activities or approaches the therapist could use.

● Identify an approach being used by the therapist ○ Sensory Integration ● Defend why the group chose the approach ○ Uses controlled multi-sensory activities that incorporate vestibular, proprioceptive, and/or tactile input ■ (tactile: feeling the shapes and letters, feeling the pillows, feeling the scooter board) ○ Approach is intended to help improve movement, body awareness, and sensory processing ■ "just right challenge," active, and child directed ● Critique the session and identify additional activities or approaches the therapist could use. ○ Co-Op approach to improve her problem-solving (one example that was used was asking "does 2+2=4?" → But expanding on this approach in order to help the child identify, develop, and use cognitive strategies to complete daily occupations ○ NDT- providing facilitation techniques to specific muscle groups to elicit proper postural responses ○ Behavioral-providing positive reinforcement and identifying specific areas in need of improvement; modeling: slowing down, looking and focusing to improve attention

Peds Exam 1

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