Anna FernBuneo PT MA CNDT PCS PT Clinical Specialist Phoenix Childrens Hospital October 26 2018 Who is the Pediatric Physical Therapist 3400 PTs in AZ 80 are in the Pediatric Section ID: 912184
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Gross Motor Delay in Early Development: An Early Intervention Physical Therapist’s Approach
Anna Fern-Buneo PT, MA, C/NDT, PCSPT Clinical SpecialistPhoenix Children’s HospitalOctober 26, 2018
Slide2Who is the Pediatric Physical Therapist?
3,400 PTs in AZ
80 are in the Pediatric Section
25 of them are Board Certified in
Peds
5 PCS PT’s here at PCH
3 more approved to sit for exam in 2019
Slide3PT at PCH-
Three Service Lines-Acute Care
Inpatient Rehab-12 bed unit
Outpatient-Neuro Team
OP Clinics
Gait Lab
4 of 5 satellite clinics staff PT
Slide4Slide5TWO New Sports Medicine PT Clinics Open Fall 2018
Slide6What is Early Intervention?
Children birth to 3 and their families. PT, OT, Speech/Feeding, and other servicesPublicly funded and available in every state and territory
Based on eligibility1. https://www.cdc.gov/ncbddd/actearly/parents/states.html
Slide7Education for all Handicapped Children Act-1975
Individuals with Disabilities Education Act (IDEA)-1990Individuals with Disabilities Education and Improvement Act
(2004)Federal law provides partial funding to states Part B-Special Ed 3-21 y/o
Part C-Infants and Toddlers with Disabilities
2.
https://sites.ed.gov/idea/
Slide8Arizona Early Intervention Program (AZEIP)
•
Teams are identified by Region.•Each child has a designated team•Team lead is established by family/concern
•Additional areas of concern- covisits are established with the TL.
3.
https://des.az.gov/services/disabilities/early-intervention/arizona-early-intervention-program-azeip-eligibility/
.
Slide9When do you refer to EI?
Slide10Are there Normal Variants in Development?
4. Adolf, K & Robinson, S
. Motor Development. In Press.
Slide11Musculoskeletal Variants
10% of referrals to PCP are for MS concerns
Slide12Motor Variants
12 months
6 years
Slide13Motor Variants
2 months
5 months
Slide14Not a Normal Variant!
Slide15Really Not a Normal Variant!
Slide16Sleep Suits Restrict Movement
Merlin Suit
Wombie
Slide17Infant Walker Should be Banned!
Banned in Canada since 2004
AAP recommends ban here
What about risks to development?
1999 –J of Developmental & Behavioral Peds (5)
Need for further research
Slide18Is Toe Walking a Normal Variant of Development?
May be a hallmark of underlying pathology or Sensory Processing Disorder (6)
If not=Idiopathic
"They will grow out of it."
"Give them until they are two."
Sensory Profile Checklist
https://www.pearsonclinical.com/therapy/products/100000822/sensory-profile-2.html
Concern if unilateral or sudden onset
Slide19"Safe to Sleep"
1994-AAP started "Back to Sleep" Campaign
4700 infants died of SIDS in 19931500 in 2016 SIDS rates in the United States have decreased by almost 50%! (7)
Slide20How Has Back to Sleep Affected Development?
Prospective Study 1998 (8)
351 infants, 2 –6 mos.Parents recorded sleep position and awake tummy time
Developmental logProne sleepers acquired motor milestones earlier
No impact on later walking
Slide21What else has Back to Sleep
Affected?
Retrospective study, J of Craniofacial Surg, 2015-390% increase in referrals for treatment of
plagiocephay
compared to before
Back to Sleep, 1992. (9)
Slide22Torticollis
Slide23Back to Sleep, Tummy to Play!
Slide24What are Red Flags?
Static or regressive development
Early hand dominance
Asymmetry in strength or tone
Decreased strength
Hyper/Hypotonia
2 month delay, < 1 y/o=> referral
4 month delay, 1-2 y/o=>referral
Slide25Always Listen to the Parent!
If the parent is concerned, generally there is cause for concern
Developmental screening using parental reports or other instruments can be more accurate than clinical judgments. (10)
Slide26What are Differences Between EI and Medical Model Intervention?
What’s In?
Team-based model
Team Lead with support as needed
Coaching interaction
Natural learning opportunities
Routines-based
Frequency is individualized based on family's needs
Skills-based treatment
Therapist-led sessions
Unnatural environment
Several sessions per week
Frequency depends on therapist recommendation
What’s Out?
Slide27What is Coaching?
Observation
Action
Reflection
Feedback
Joint Plan
Slide28Signicant delay
in one of more of the following domains:
Gross/Fine MotorCognitive
Communication (Expressive/Receptive)Social-Emotional
Adaptive/Self-help
*Standard Score of 70 0r below.
*Clinical Opinion
.
AZEIP Definition of Developmental Delay
Slide29Established Conditions
Cerebral Palsy
Chromosomal AbnormalitiesFailure to Thrive/Undernutrition
Metabolic DisordersSpina BifidaSignificant Auditory or Visual Impairment
Periventricular Leukomalacia
Severe Attachment Disorders
Disorders secondary to Toxic Exposure I.e. Fetal Alcohol Syndrome
Disorders of Nervous System-ASD, Seizures, Drug addiction
IVH Grades III, IV
Slide30Slide31Slide32Slide33Triplets now almost 4!
Slide34For concerns about AZEIP services anyone can call the AZEIP office at 602-532-9960.
Slide35References
1. What is Early Intervention. Available at:
https://www.cdc.gov/ncbddd/actearly/parents/states.html
. Accessed October 5, 2018. 2. Individuals with Disabilities Education Act. Available at: https://sites.ed.gov/idea/. Accessed October 5, 2018.
3. Arizona Early Intervention Program. Available at:
https://des.az.gov/services/disabilities/early-intervention/arizona-early-intervention-program-azeip-eligibility/
. Accessed October 5, 2018.
4. Adolf, K & Robinson, S. Motor Development. In Press.
5. Siegel AC, Burton RV. Effects of Baby Walkers on Motor and Mental Development in Human Infants.
Journal of Developmental and Behavioral Pediatrics.
1999; 20 (5) 355-61.
6. Williams CM, Tinley P, Curtin M. Idiopathic Toe walking and Sensory Processing Dysfunction.
Journal of Foot Ankle Research.
2010; 16: 3-16.
Slide36References
7. Trachtenberg, F. L., Haas, E. A., Kinney, H. C., Stanley, C., & Krous, H. F. Risk factor changes for sudden infant death syndrome after initiation of Back-to-Sleep campaign.
Pediatrics. 2012; 129: 630-638.
8. Davis BE, Moon RY, Sachs HC, and Ottolini MC. Effects of Sleep Position on Infant Motor Development. Pediatrics.
1998; 102 (5): 1135-40.
9. Branch LG,
Kesty
K, Wright L, Leger S, David LR. Deformational Plagiocephaly and Craniosynostosis: Trends in Diagnosis and Treatment after the "Back to Sleep" campaign.
J Craniofac Surg.
2015; 26(1):147-50.
10. Gupta VB.
Manual of Developmental and Behavioral Problems in Children. New York: Marcel Dekker, Inc.; 199.
Peitsch
WK, Keefer CH,
LaBrie
RA,
Mulliken
JB. Incidence of Cranial Asymmetry in Healthy Newborns.
Pediatrics.
2002;110:e72.
Tervo RC. Parent’s reports predict their child’s developmental problems.
Clinical Pediatrics.
2005; 44: 601-11.
Slide37Thank you!
Afernbuneo@phoenixchildrens.com