Final exam Childhood .pdf

Childhood and Occupational Development Best ways for parents to develop attachments with children Touch, smell, and movement sensations are important to the newborn infant, who uses these to maintain contact with a caregiver through nursing, nuzzling, and cuddling. Tactile s...

Childhood and Occupational Development Best ways for parents to develop attachments with children Touch, smell, and movement sensations are important to the newborn infant, who uses these to maintain contact with a caregiver through nursing, nuzzling, and cuddling. Tactile sensations are critical in establishing primary attachment relationships with a caregiver and fostering feelings of security in the infant. - This is just the beginning of the important role that the tactile system play’s in a person’s emotional life because it is directly involved in making physical contact with others. Proprioception is also critical in the mother-infant relationship, enabling the infant to mold to the adult caregiver’s body in a cuddly manner. Together, these tactile and proprioceptive inputs set the stage for the eventual development of body scheme (the brain’s map of the body and how its parts interrelate). Ecocultural framework Established and revised by Bronfenbrenner. In this model, child development is situated as a reciprocal interrelationship between the characteristics of the child and the environments in which they engage. Emphasizes the importance of the context on child development and explains the reciprocal interactions among and between the child, family, community, and geopolitical contexts on a child’s occupational participation and performance. Transaction between any and among contexts promotes occupational development through building strong relationships and changing the environment. The bioecological model emphasizes the importance of the physical, social, cultural, virtual, and temporal context on child development and explains the reciprocal interactions among and between the child, family, community, and geopolitical contexts on a child’s occupational participation and performance. There are five contextual layers to the bioecological model: Layer 1- Individual Child: The child participates and performs in occupations based on their current skills, physical and mental health, and under the influence of environmental factors. Attachment to caregivers provides the child with an understanding of emotions and social relationships. - Genetics  - Adverse childhood experiences - Resiliency Layer 2-Caregivers: Parents’ educational level, work, socioeconomic status, gender, ethnicity, cultural beliefs, and their own physical and mental health influence the child’s occupations. When caregivers are sensitive and responsive to the infant, healthy social-emotional development results - Socio-emotional status - Education - Health - Availability Layer 3-Family Context: involves the family structure and the physical environment of the family home. Family factors include attentiveness to a child’s needs, positive regard, and engagement in family routines. Also includes cultural traditions and philosophies of child rearing, including acceptance of disability. Cultural influences on social play behaviors include time and space to play, access to objects and materials, adult behavior and attitudes, and the availability of play partners - Support of hindrance Layer 4- Community: consists of institutions and people outside of the family structure. This includes peers, school, neighborhoods, religious institutions, and accessible transportation. Characteristics of community environments can become barriers or opportunities to occupational participation. - Funded child activities: sports, recreation centers - Access to playgrounds - Safe schools - Public transportation - Green spaces Layer 5- Geopolitical Contexts: affect the broader world in which children live. Invokes the concepts of occupational justice, occupational alienation, and deprivation, which limit an individual’s participation in living the life he or she chooses based on broader contexts out of his or her immediate control (e.g., healthcare policies, racism, sexism, ableism). An important aspect of the geopolitical context is the formation of a knowledge economy, which refers to the for-profit, information-based society (e.g., Governmental trade and policies have made technology more available and affordable). As a transactional model, the bioecological model illustrates the occupational science theory of doing, being, becoming, and belonging and demonstrates how transactions within and among contexts (e.g., physical, social, political) support or hinder the child’s occupational development. Dynamic systems theory and ecological theory are two frameworks that view motor actions as complex results of the interactions between persons, tasks, and environments. Dynamic Systems Theory Dynamic systems theory refers to performance or action patterns that emerge from the interaction and cooperation of many systems, both internal and external to the child. In the context of occupational development, performance emerges from the interactions of an individual’s neurophysiological systems, social emotional responses, and the contextual environments that provide opportunities and affordances to achieve a functional goal. Reciprocal transactions occur between and among internal and external contexts of the child. Kielhofner Model of Human Occupation Kielhofner’s Model of Human Occupation (MOHO) is the most widely used and researched occupation-centered model of practice. MOHO emphasizes the dynamic nature of occupational performance. It includes four elements: volition, habituation, performance capacity, and environment. Children and youth develop an identity through their performance (occupational identity) and learn to adapt and modify to accomplish those things that are meaningful and important to them (occupations). Therefore the goal of occupational therapy intervention is occupational identity and the ability to engage in a variety of occupations. Volition includes one’s values, interests, and personal causation. Values are those things that are important to the child Interests are those things preferred and perceived as pleasurable. Personal causation refers to a person’s belief in their abilities and effectiveness to engage in those things they find meaningful (self-efficacy). Habituation includes one’s habits and roles. MOHO examines the child’s view of the expectations of the role and feelings that he or she can fulfill the role. Performance capacity refers to the person’s mental and physical abilities required to participate in daily activities as well as the person’s subjective experience and view of their occupational performance. Environment consists of the physical, social, occupational and cultural, economic, and political contexts. Many models and frames of reference address the child’s abilities and skills. MOHO expands performance capacity to include the child’s personal experience and viewpoint of his or her abilities. The child’s subjective experience of his or her performance is important to the child’s occupational identity. MOHO proposes that human behaviors are the result of the interaction of person factors (volition, habituation, performance capacity within the environment. As children experience occupational shifts (including changes in how they perform or think about things), they establish new ways of performing (occupational adaptation), which creates their occupational identity. MOHO indudes six assessments specifically created to be used with children and youth The assessments are easy to administer and can be adapted to meet the needs of a variety of children and youth. MOHO lists nine therapeutic methods to facilitate change in occupational performance: validating, identifying, giving feedback, advising, negotiating, structuring, coaching, encouraging, and providing physical support. The Canadian Model of Occupational Performance and Engagement (CMOP-E) CMOP-E emphasizes enablement, social justice, and environment to promote occupational engagement. The term enablement refers to helping people through empowerment and is a positive form of the term disablement Social justice refers to a “vision and everyday practice in which people can choose, organize, and engage in meaningful occupations that enhance health, quality of life, and equity in housing, employment, and other aspects of life. CMOP-E defines environment as the cultural, institutional, physical, and social aspects that influence occupational performance. Engagement includes the client’s participation in everyday activities that provide him or her with meaning (occupations). The CMOP-E views the person’s spirituality as the core of the model. Cognition, affect, and physical factors are key aspects of the person element. CMOP-E emphasizes social and occupational justice. CMOP-E defines occupations as self-care, productivity (school, work, volunteering), and leisure (play). This model focuses on creating a supportive environment and advancing health, well-being, and justice. Canadian Occupational Performance Measurement (COPM) was developed to align with the CMOP-E. The COPM can be used as a semi-structured interview for parents and possibly adolescents. The occupational therapist engages children and youth in setting goals, making choices, and engaging in daily living The occupational therapist views the child and his or her strengths, abilities, demand motivations as center to the intervention, while also evaluating the child’s physical, neurological, and musculoskeletal abilities within the home, community, and political environment. CMOP-E views the collaborative process as essential to facilitating change. Person-Environment-Occupation-Performance Model (PEOP) Focuses equally on facilitating change in the person, occupation, or environment for participation in desired occupations. PEOP emphasizes the importance of the person’s narrative, which is defined as ’the past, current and future perceptions, choices, interests, goals, and needs that are unique to the person, organization, or population. Occupations consist of activities, tasks, roles, and classifications of the everyday things that children and youth do. The PEOP model suggests that occupational performance is the result of the dynamic, transactive relationship involving person, environment, and occupation. The PEOP model can be used as an analytic tool to identify factors in the person, environment, or occupation that facilitate or hinder the participation in occupations chosen by the person. The goal of occupational performance is participation and well-being. The guiding principles of PEOP emphasize the active doing of occupational performance, with a strong collaboration between the occupational therapist and client, which includes an understanding of the person’s narrative. By making changes in one or more factors, children and families may engage more fully in occupations, leading to improved participation and well-being. PEOP does not have any specific assessments associated with the model directly. Occupational Adaptation The Occupational Adaptation (OA) Model proposes that people participate in desired occupations because of a press for mastery (which involves occupational roles, role demands, challenges, and responses). This is influenced by one’s person factors (cognitive, sensory, motor, and psychosocial) and the contexts (physical, social, cultural, temporal, personal, virtual) OA refers to the child or youth’s ability to participate in a desired occupation and change their performance based upon the required demands. OA suggests that people desire to master the environment and participate in occupation. The environment is not rigid, but rather requires people to adapt and change responses. The press for mastery involves expectations and requirements of occupational roles, role demands, challenges, and responses. The press for mastery is the result of the person’s level of competency and the environment’s demand, which requires a person to adapt or respond differently depending on the given demand. OA model defines relative mastery as having three important properties: Effectiveness participation, Efficiency, and Satisfaction. The emphasis of the OA model is to empower children and youth to make changes, create new strategies, or use resources so they can engage in meaningful occupations. Ecocultural frame and modifications As a transactional model, the bioecological model illustrates the occupational science theory of doing, being, becoming, and belonging and demonstrates how transactions within and among contexts (e.g., physical, social, political) support or hinder the child’s occupational development. For example, the environment may support and interact with the child’s actions, compelling the child to adapt or accommodate. Conversely a context may have limits and challenges, such as an inaccessible playground for a child in a wheelchair. Through adaptation and accommodation for the child’s needs (e.g., learning disability, physical disability), family needs, physical environment, and access to financial and community resources, the child is likely to achieve occupational participation, competence, and the developmental maturation necessary for generalization of occupational skill, continued learning, and physical and mental wellness. The role of the occupational therapist in this transactional model is to promote occupational justice through adapting and transforming environments to support occupational performance. Person environment incongruence Reciprocal transactions occur between and among internal and external contexts of the child. The characteristics of the child and the social, physical, cultural, and virtual environments interact to provide relational flow between the person and their situations. *This is not occurring if there is person environment incongruence. A child’s actions and behaviors must be understood as coherent occupations within specific contexts. Hocking (2009) defines this process as occupational forms. Occupational forms, “elicit, guide, and structure occupational performance...This includes both the immediate physical environment in which the performance takes place and its socio-cultural reality. The form influences what is done. *This is not occurring if there is person environment incongruence. Physical, psychological, social-emotional, or mental trauma may interfere with the progression and sequence, causing a “gap” in the child’s development. Llorens (1997,1982) hypothesized, as a child participates in the family’s cultural, social, and temporal practices, the child learns occupations and performance skills that enable him or her to become a full participant in the home and extended community. Oriented environments are physically safe, emotionally secure, and psychologically enabling, allowing children and adolescents the opportunity to explore and gain competencies and a positive sense of self. Occupation as a means and occupation as an end An occupation-centered lens of development emphasizes occupational therapy’s unique focus on functional participation in occupation as both a means and an end. Using this method, a collaborative approach is used to determine goals and to understand a client’s interests. The OT then uses their skills of occupational analysis to determine which underlying performance skills and/or client factors may need to be challenged. The OT then chooses activities related to the client’s occupations and interests that can be modified and structured to improve desired areas. Occupation as Means Refers to the occupation acting as the therapeutic change agent to remediate impaired abilities or capacities. Examples include using manipulation of game pieces to acquire or reacquire dexterity, placing game pieces out of reach to promote postural control, or using the game to develop social skills such as turn taking. It is particularly important that the OT choose occupations that have meaning and the rationale for the intervention is made explicit. Occupations as an End Refers to engaging the client in occupations that constitute the end product of therapy (i.e. the occupations to be learned or relearned). Using occupations as ends in intervention serves as the goal to be learned or achieved. Typical Development and milestones – motor, cognition, functional such as self feeding, holding a cup, spoon, dressing Gross Motor Skills Birth-6 months - Lifts head (3-4 months), raises trunk when prone (4-6 months) - Kicks reciprocally when supine - Sits propping on hands - Plays (bounces) when standing with support from parents - Rolls from place to place 6-12 Months - Sits independently - Rolls from place to place - Independently gets into sitting position - Pivots in sitting position - Stands, holding on for support - Plays in standing when leaning on support - Crawls on belly initially, then crawls on all fours (10 months) - Walks with hand held (12 months) (Cruising) 12-18 Months - Sits in small chair - Plays in standing - Walks well, squats, picks up toys from the floor - Climbs into adult chair - Flings ball - Pulls toys when walking - Begins to run - Walks upstairs with one hand held - Pushes and pulls large toys or boxes on floor 18-24 Months - Runs, squats, climbs on furniture - Climbs on jungle gym and slides - Moves on ride-on toy without pedals (kiddy car) - Kicks ball forward - Throws ball at large target - Jumps with both feet (in place) - Walks up and down stairs 24-36 Months  - Rides tricycle - Catches large ball against chest - Jumps from step or small height - Begins to hop on one foot 3-4 Years - Jumps, climbs, runs - Begins to skip and hop - Rides tricycle - Stands briefly on one foot - Alternates feet walking upstairs - Jumps from step with 2 feet 4-5 Years - Jumps down from high step; jumps forward - Throws ball - Hops for long sequences (4-6 steps) - Climbs on playground equipment, swinging from arms or legs - Throws ball and hits target - Skips for a long distance - Walks up and down stairs reciprocally 5-6 Years - Hops well for long distances - Skips with good balance - Catches ball with two hands - Kicks with accuracy - Stands on one foot for 8-10 seconds 6-10 Years - Runs with speed and endurance - Jumps, hops, skips - Throws ball well at long distances - Catches ball with accuracy Fine Motor Skills Birth-6 months - Follows moving person with eyes - Develops accurate reach to object - Uses variety of palmar grasping patterns  - Secures object with hand and brings to mouth - Transfers objects hand-to-hand - Examines objects carefully with eyes - Plays with hands at midline 6-12 months - Mouths toys - Uses accurate and direct reach for toys - Plays with toys at midline: transfers hand to hand - Bangs objects together to make sounds - Waves toys in air - Releases toys into container - Rolls ball to adult - Grasps small objects in fingertips - Points to toys with index finger, user index finger to explore toys 12-18 months - Holds crayon and makes marks; scribbles - Holds two toys in hand and toys in both hands - Releases toys inside containers, even small containers - Stacks blocks and fits toys into form space (places pieces in board) - Attempts puzzles - Opens and shuts toy boxes or containers - Points to pictures with index finger - Uses two hands in play, one to hold or stabilize and one to manipulate 18-24 months - Completes four- to five-piece puzzle - Builds towers (e.g., four blocks) - Holds crayon in fingertips and draws simple figures (straight stroke or circular stroke) - Strings beads - Begins to use simple tools (e g., play hammer) - Participates in multipart tasks - Turns pages of book 24-36 months - Snips with scissors - Traces form, such as a cross  - Colors in large forms - Draws circles accurately - Builds towers and lines up objects - Holds crayon with dexterity - Completes puzzles of four to five pieces - Plays with toys with moving parts 3-4 years - Uses precision (tripod) grasp on pencil or crayon - Colors within lines - Copies simple shapes; begins to copy letters - Uses scissors to cut cuts simple shapes - Constructs three dimensional design (e.g., three block bridge) - Manipulates objects within the hand 4-5 years - Draws using a dynamic tripod grasp - Copies simple shapes - Completes puzzles of up to 10 pieces - Uses scissors to cut out squares and other simple shapes - Colors within the lines - Uses two hands together well, one stabilizing paper or object and the other manipulating object - Draws stick figure or may begin to draw trunk and arms - Copies own name - Strings small beads 5-6 years - Cuts with scissors - Prints name from copy - Copies triangle; traces diamond - Completes puzzles of up to 20 pieces - Traces letters, begins to copy letters - Manipulates tiny objects in fingertips without dropping - Uses two hands together in complementary movements 6-10 years - Good dexterity for crafts and construction with small objects - Bilateral coordination for building complex structure  - Precision and motor planning evident in drawing - Motor planning evident in completion of complex puzzles Cognitive milestones Birth-6 months - Repeats actions for pleasurable experiences - Uses hands and mouth to explore objects - Searches with eyes for sounds - Bangs objects on table - Integrates information from multiple sensory systems 6-12 months - Responds to own name - Recognizes words and family members names - Responds with appropriate gestures - Listens selectively - Imitates simple gestures - Looks at picture book - Begins to generalize from past experiences - Acts with intention on toys - Takes objects out of container 12-18 months - Acts on object using variety of schemas - Imitates model - Symbolic play with real props (e.g., pretends to drink with cup) - Understands how objects work - Understands function of objects - Uses trial-and-error in problem solving - Recognizes names of various body parts 18-24 months - Links multiple steps together - Has inanimate object perform action - Begins to use non-realistic objects in pretend play - Continues to use objects according to functional purpose - Object permanence is completely developed 24-36 months  - Combines actions into entire play scenario (e.g., feeding doll, then dressing in nightwear, then putting to bed) - Shows interest in wearing costumes; creates entire scripts of imaginative play - Matches pictures - Sorts shapes and colors - Play house 3-4 years - Uses imaginary objects in play - Makes dolls and action figures carry out roles and interact with other toys - Categorizes and sorts objects - Shows a sense of humor 4-5 years - Understands rules to game - Remembers rules with a few reminders - Makes up stories that involve role playing with other children - Participates in goal-oriented, cooperative play with 2 or 3 other children - Participates in planning a play activity - Begins abstract problem solving 5-6 years - Reasons through simple problems - Bases play more on real life than on imaginary world - Participates in organized games - Uses complex scripts in play - Demonstrates deferred imitation - Sorts objects in different ways - Copies elaborate block structures 6-10 years - Abstract reasoning - Performs mental operations without need to try physically - Demonstrates flexible problem solving - Solves complex problems Developmental Progression from Bottle to Cup 2 to 4 months - Moves hand/hands up to the bottle/breast while feeding 6 to 9 months  - Holds a bottle with both hands - Uses a cup with help 12 to 15 months - Holds a cup with both hands - Takes a few sips without help 15 to 18 months - Uses a straw 24 to 23 months - Drinks from a cup (no lid) without spilling Developmental Progression for Self-feeding 6 to 9 months - Wants help with feeding - Starts holding and mouthing large crackers/cookies - Plays with spoon; grabs /bangs spoon; puts both ends in mouth 9 to 13 months - Finger feeds soft foods and foods that melt quickly - Enjoys finger feeding 13 to 14 months - Moves spoon to mouth but is messy 15 to 18 months - Scoops food with a spoon and feeds self 18 to 24 months - Wants to feed himself/herself 2 to 3 years - Stabs food with fork - Uses spoon without spilling 3 to 5 years - Eats by himself/herself Developmental Progression of Dressing Skills 1 year - Removes sock - Puts on and takes off a loose-fitting hat - Helps with dressing by pushing arms through sleeves and legs through pants - Opening 2 year - Removes shoes - Removes simple clothing such as pushing down pants or pulling off socks - Once a shirt is over their head, they can find and push their arms through the shirt opening 2 and a half - Attempts to put on socks - Unbuttons a large button - Puts on easy clothing such as jackets or open-front shirts without zipping or buttoning them 3 year - Puts on a t-shirt with a little help - Puts on shoes, although the right and left orientation may be incorrect - Puts on socks with a little help for the correct orientation of the heel - Pulls down simple clothing (i.e., pants with elastic waistband) independently - Buttons large front buttons - Zips and unzips a jacket if the shank is already connected 3 and a half - Unzips a jacket and separates the shank - Buttons three or four buttons - Unbuckles a belt with practice - Finds the front side of clothing and dresses themselves with supervision 4 year - Inserts the shank together to zip up a jacket with practices - Laces shoes - Places sock with appropriate orientation 5 year - Dresses independently  Play Types of play at different developmental stages (infancy up) Birth-6 months - Exploratory 6-12 months - Exploratory - Functional play (use toys according to their purpose) 12-18 months - Relational and functional play 18-24 months - Functional play 24-36 months - Symbolic play - Constructive play 3-4 years - Complex imaginary play - Constructive play - Rough and tumble play - Social play 4-5 years - Games with rules - Constructive play - Social play/dramatic play 5-6 years - Games with rules - Dramatic play - Sports - Social play 6 to 10 years - Games with rules - Crafts and hobbies - Organized sports  - Social play Games with rules (developmental age skill) 4-5 years - Begins group games with simple rules - Engages in organized play with prescribed roles - Participates in organized gross motor games such as kickball or duck duck goose 5-6 years - Board games - Computer games - Competitive or cooperative games 6-10 years - Computer games, card games, that require problem solving and abstract thinking Definition of playfulness – differentiate from play Playfulness: A child's experience or state of mind when playing. Elements of playfulness: - Intrinsic motivation - Internal control - Ability to suspend reality Play: Hard to define but has specific characteristics - Spontaneous, fun, or joyful - Intrinsically motivated and internally controlled Factors that inhibit play Not all children have the same access to good playgrounds, accessible playgrounds, or natural outdoor play spaces. Many children with disabilities experience significant barriers to play. Multiple physical and social barriers impede play, such as bad weather, mobility equipment and restrictions, limited choices, wheelchair usage, along with peer rejection, low expectations, and fears of caregivers or other adults in relation to child safety. The lack of a home environment can also hinder play. The effects of play deprivation can be seen in children who have experienced long hospitalizations. Extreme examples of constraints to play have been seen in reports of children from orphanages. Children from orphanages who receive only basic care show severe sensory problems, delays in development, and difficulties interacting with others. Children who experience severely deprived environments may also exhibit self-stimulation, a limited repertoire of activities, and minimal social play. Intrinsic motivation Refers to the self-initiation or drive to action whereby the reward is the activity itself Framing Children understand that they are engaging in play, which is known as framing the play (Bundy, 1997). Framing implies that players understand they are playing and should act accordingly. The Test of Playfulness measures framing along with intrinsic motivation, internal control, and freedom to suspend reality, which are the four elements of playfulness. Environmental play assessments Play and leisure assessments provide the OT with a picture of how the individual engages in play/leisure in his or her daily life However, assessments that are designed to take place in standardized settings, such as those that are embedded within developmental assessments with standardized toys, significantly alter and may inhibit the child’s play Play assessments for use in natural environments, and leisure assessments via self-report may provide the most valid information There are a variety of play/leisure assessments available currently: The Test of Environmental Supportiveness (TOES) assesses the child’s environment capacity to support playfulness A client focused activity analysis refers to a highly individualized analysis of the personal way in which an activity or occupation is performed in real-life contexts by a specific individual Role of physical and social environment in play Physical Environment: physical environments in relation to play consist of playgrounds, outdoor and natural play spaces, indoor, classroom, or home play spaces, as well as the types of toys and materials available to play. Different types of playgrounds may encourage different types of play. Children may be more social and enjoy play more in outdoor natural environments than with highly structured playgrounds. Safe play environments with varied age appropriate toys encourage children. Natural environments provide opportunities for more complex and creative play and children often prefer natural play spaces to playgrounds. Adventure playground often looks like a junk heap, as it is filled with “cast off” objects and scraps that children can build with, climb on, and do what they please with. Social Environments: refer to other individuals available for play, the types of interactions that happen through play, and the impact of play partners on play. For example, child play skills may be influenced by parental beliefs about play importance; social play interaction may vary with adult presence and nurturing, supportive, and responsive caregivers may lead to more competent play. Play may vary based on the gender of the play partner. Playfulness may vary based on the play partner as well. Parenting styles, parental restrictions, and adult presence and interactions may also influence/impact childrens play.  Working with Families Considerations under ecocultural framework Families provide children with a cultural foundation for their development as occupational beings. Family members share and transmit a cultural model, a habitual framework for thinking about events, for determining which activities should be done and when, and for deciding on how to interact. By prosiding a cultural foundation, families ensure that children learn how to approach, perform, and experience activities in a manner consistent x-ith those in their cultural group. In the context of receiving care and sharing in family activities, children acquire skills that lead to their independence in activities of daily living (ADLs) and learn habits that will influence their health across their lifespan. A family functions as a dynamic system in which its members influence the activities of other members and engage in occupations together to fulfill the functions of the family. These interdependent influences define the dynamic relationship among the different parts, similar to the movement of a piece on a hanging mobile that causes movement of all the other parts. An ecological view (environmental) and transactional perspective of development and parenting encourages occupational therapists to consider family resources and the adult’s psychological background, personal history, and personality, which are in constant interaction with characteristics of the child being patented. Multidisciplinary approach Team members communicate their individual plans of care to each other. Interdisciplinary approach Team members analyze and synthesize their plans of care. A family functions as a dynamic system in which its members influence the activities of other members and engage in occupations together to fulfill the functions of family. These interdependent influences define the dynamic relationship among the different parts, similar to the movement of a piece on a hanging mobile that causes movement of all the other parts. Recognizing that a family functions as a unit, an occupational therapist who suggests an after-school horseback riding class for a child with cerebral palsy needs to appreciate that the recommendation must be weighed considering the family resources and the implications of that activity for the entire family system.  Evaluation and Intervention Process Who is involved, roles, impact on family culture, school and different setting Occupational therapists tailor the evaluation plan for children and youth to address the concerns of parents. When working with pediatric populations, the OTs collaborate with a client constellation which is a pair or group of individuals who provide input regarding the therapeutic process and benefit from outcomes associated with services. The parent’s perspective must be examined at the outset of the therapeutic relationship. Understanding the parent’s concerns will help reduce any disconnect between the parent’s preferences and values and the occupational therapist’s approach to evaluation To establish the scope and frequency of intervention, occupational therapists conduct a comprehensive evaluation and collect data from numerous sources (e.g., child, parent, teacher) and with multiple methods (e.g., parent interview, observation of the child in various environments, standardized assessment tools). The understanding of the child’s concerns is shaped by multiple perspectives and it is important to note that adults in the child’s life (e.g., parents or teachers) might identify an area of concern that is not viewed as a “problem” or difficulty by the child. It is up to the therapist to work with the entire client constellation to negotiate the focus and priorities of therapy. How the data is collected and through which mechanisms is often determined, in part, by the practice setting. The frequency and duration are often determined by the therapist’s experience working with children with similar presentations and developmental trajectories, funding and legal parameters, or other factors associated with the setting (e.g., a therapist working in a school setting might typically see a child for an academic year). Knowledge of the purpose of popular and common assessments used such as SFA, BOT, PDMS-2. School Function Assessment (SFA) A criterion-referenced assessment; rating scales for the educational team to complete. - Assesses strengths and needs in the school for children in kindergarten-6th Is a judgment-based questionnaire completed by one or more school professionals familiar with the child’s performance at school. Criteria for rating the child’s performance on each item are provided. School professionals are encouraged to collaborate in determining ratings and to use these ratings as a basis to collaborate in determining ratings and to use these ratings as a basis for designing an intervention plan. Rates functional performance for academic tasks and related areas of school performance. Process facilitates collaborative planning. Three scales: participation, task supports, and activity performance. The SFA, although primarily a criterion referenced test, provides a criterion score and standard error for each raw score based on a national standardization sample. Bruininks-Oseretsky Test of Motor Proficiency (BOT-2) Norm-referenced tests address one or more areas of behavior. If the test evaluates more than one area, each area typically has one or more subtests. - Assess motor performance children ages 4-21. Comprehensive assessment of motor proficiency For instance, the BOT-2 assesses performance in four motor-area composites: fine manual control, manual coordination, body coordination, and strength and agility- Items are chosen to represent a broad range of skills within these composite areas, and developers often will select the items that had the best discriminative ability between typical and atypical populations. Assesses overall moto proficiency along with gross and fine motor skills. Includes subtests of fine-motor precision, fine-motor integration, manual dexterity, bilateral coordination, balance, running speed and agility, upper-limb coordination, and strength. Additionally items are chosen to incorporate materials and activities that are reasonably familiar and typical for children of the age group being tested. A child’s performance on an individual test item is not as important as the overall subtest or area score. However, it is important for the occupational therapist to observe the quality and characteristics of a child’s performance on each item, as these qualitative observations provide important information to complement the obtained standard scores. Peabody Developmental Motor Scales (PDMS-2) Both a norm referenced and criterion-referenced test. Performance based. - Designed to assess the motor skills of children from birth through 6 years old. Has been subjected to the statistical analyses used in norm referenced tests, many individual items in the test also represent developmental milestones that can be targeted as specific intervention goals. An early childhood early developmental program that provides both an in-depth assessment and training or remediation of gross and fine motor skills. Composed of 6 subtests that measure interrelated motor abilities that develop early in life (reflexes, stationary, locomotion, object manipulation, grasping, and visual-motor integration). Theoretical approach Top Down/Bottom Up Top Down Therapist begins the evaluation process by gaining an understanding of the child’s level of participation in daily occupations and routines with family, other caregiving adults, and peers. The examination of specific skills and client factors come later. Bottom Up The therapist first evaluates client factors to understand what might be limiting a child’s performance skills and occupational performance. Some authors argue for the importance of both types of assessment approaches and a combined approach. Considerations in designing goals and intervention Standardized tests provide information about a child’s level of function, and they help occupational therapists determine the appropriate starting point for therapy intervention. Most commonly, criterion-referenced standardized tests are used as the basis for developing goals and objectives for children and measuring progress and change over time. The occupational therapist’s interpretation of the evaluation findings need to be conceptually congruent with the child’s occupational profile, the goals that are established for intervention, and the intervention plan. When working with children, intervention goals may be focused on the child’s individual occupational performance and/or their participation during co-occupation. In addition, occupational therapy goals should be based on the progress trajectory that the occupational therapist predicts based on the progress trajectory that the occupational therapist predicts based on knowledge of the child and family, the context or environment, and previous professional experience. How to best report results to a parent Occupational therapists should be very cognizant of the language that is used when writing evaluation reports. The use of harsh or judgmental language (e.g., “the child can’t do anything;” “the child is noncompliant”) or generalizations (e.g., “the child always has tantrums”) does little to paint a comprehensive and nuanced picture of the child and may also be offensive to the child, the child’s parents, or other providers. Leading with the child’s strengths and using objective language to frame the child’s difficulties is better practice. Regarding language, occupational therapists should use appropriate terminology for the setting (i.e., “patient*’ or “student” or “child”) and explain professional jargon. Understanding family culture Tests developed primarily on a white, middle class population may not be valid when used with children from diverse cultural backgrounds It is important for examiners to be aware of the factors that may influence how children from diverse cultures perform on standardized tests For example, some children may not have any experience with testing and may not understand the spoken rules about test taking Some might not understand the importance of doing a task within the time limit or following the examiner’s instructions They may not be motivated to perform well on tests because the task itself has no intrinsic meaning to them The materials or activities may be seen as irrelevant, or the child, having had no experience with the kinds of materials being used in the tests, may not know how to interact with them Establishing rapport may be difficult either because of language barriers or because of a cultural mismatch between the child’s social interaction patterns and those of the examiner If the examiner is aware of these potential problems, steps can be taken to minimize possible difficulties Standardized tests should be used cautiously with children from diverse cultures OTs would find themselves frequently evaluating children from cultural or ethnic groups that are underrepresented in the normative samples of most standardized tests may want to consider developing “local norms” on frequently used instruments that reflect the typical patterns of performance among children of that culture Professional communication skills are essential when administering tests and reporting information Children who have not had any experience with testing may not understand the unspoken rules about test taking They may not be motivated to perform well on tasks because the task itself has no intrinsic meaning to them. Establishing a rapport may be difficult either because of language barriers or because of a cultural mismatch between the child’s social interaction patterns and those of the examiner. Standardized tests should be used cautiously with children from diverse cultures. Awareness of family and cultural values helps put the child’s performance in a contextual framework Best environment/naturalistic context Services for infants and toddlers must be provided in “natural environments” and services for preschool and school-aged children must be provided in the “least restrictive environment.” Intervention in natural environments includes using toys and materials that can be found in the home and will remain available to the family or other caregivers on a consistent basis. By providing early intervention services in natural environments, they take advantage of the actual contexts in which the occupations and co-occupations of children and families occur. Opportunities for learning in natural environments appear to be most effective for addressing the developmental needs of young children when the opportunities are interesting and engaging and provide children with contexts for exploring, practicing, and mastering competence. When skills are learned in the natural setting, it is more likely that they will generalize to other activities and environments. Two key advantages of providing occupational therapy in natural environments are that children tend to be more comfortable in familiar settings such as their homes and that teaching caregivers to implement natural learning opportunities within the daily routines of the child and family is feasible and practical. Measurement of participation ADLs are a key task in supporting participation and are conceptualized as a component of the Activities and Participation domain in the International Classification of Functioning Disability and Health (ICF). The Participation and Environment Measure for Children and Youth is a parent report instrument examining participation and environment across three settings: home, school, and the community. While taking a broad look at participation and environment to align with ICF, it includes information on ASLs, such as Personal Care Management under the Home setting. The Participation and Sensory Environment Questionnaire is a parent and teacher report tool to determine the impact of the sensory environment on the child’s participation. It is paired with the Parent Effort Scale, which quantifies the amount of effort a parent expends to support their child’s participation. SMART and SMART with occupational focus – know how to write this Significant and Simple,Specific Measurable Achievable Related Time-limited Significant and Simple - Know the client’s strengths and needs - In collaboration, ensures significance - Simple: more likely to achieve - Simple: easier to understand Measurable - Clear target so you know when you get there - Dress with no more than 1 verbal cue - Check daily schedule every hour Achievable - Must be reasonable and realistic - Achievable in allotted time Related - Close connection to the occupational needs as an evaluation - LTG and STG relate to each other Time-limited - Has a chronological end point - If STG is met, may need a new one - If LTG is met maybe time for discharge - If STG is not met on time, may need to be modified, continued, or discontinued  Assessments Norm vs criterion reference Norm-Referenced A norm-referenced test is developed by giving the test to a large number of children to get the average scores derived, which makes the normative sample Generally, the data is composed of children who have no developmental delay or conditions Purpose - Comparison of child’s performance with normative sample Content - General; usually covers a wide variety of skills - Address one or more areas of behavior Administration and scoring - Always standardized - If changes are made in the standardized procedures, the examiner cannot compare the child’s results to the normative sample Psychometric properties - Normal distribution of scores; means, standard deviations, and standard scores computed Item selection - Items chosen for statistical performance; may not relate to functional skills or therapy objectives Examples - BSID-III, PDMS-2, BO-2, PEDI-CAT Criterion-Referenced Tests A criterion referenced test is designed to provide information on how children perform on specific tasks The child’s performance is performed with a criterion, or level of performance of a skills The goal of this type of tests is to determine which skills a child can or can’t do, providing a focus for intervention The intent of this test is to measure a child’s performance on specific tasks rather than to compare the child’s performance with that of his or her peers Purpose - Comparison of child’s performance with a defined list of skills - Is to learn exactly what the child can accomplish, not compare the child’s performance with that of a peer group Content - Detailed; may cover specific objectives or developmental milestones Administration and scoring - May be standardized or non-standardized Psychometric properties - No score distribution needed; a child may pass or fail all items without adversely affecting the validity of the tests results Item selection - Items chosen for functional and developmental importance; provides necessary information for developing therapy objectives - Therefore these specific items have a direct relationship with functional skills and can be used as a starting point for generating appropriate goals and objectives for intervention Examples PDMS-2, PEDI-CAT, HELP, Gross-Motor Function Measure, SFA Some tests can be both norm-referenced and criterion-referenced This means that although the items have been analyzed for their ability to perform statistically, they also reflect functional or developmental skills appropriate for intervention These tests permit the occupational therapist to compare a child's performance with that appears in the normative sample and they also provide information about specific skills that may be appropriate for remediation Example of both norm & criterion referenced  - PDMS-2 Central Tendency Descriptive statistics. Represent “averages” or scores that are representative of a distribution; includes mean, median, and mode. Indicates the middle point of the distribution for a group, or sample, of children. The most frequently used measure of central tendency is the mean. Another measure of central tendency is the median, which is simply the middle score of a distribution. The median is the preferred measure of central tendency when outlying or extreme scores are present in the distribution. Standard scores vs age equivalent scores Standard Scores - The standard deviation (SD): An important number because it is the basis for computing many standard scores. It is the average deviation of scores from the mean. The larger the SD, the more variability in the group. The primary standard scores used in standardized testing are Z-scores and T-scores. - Z-score: 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, and the positive value of the second score indicates that the Z-score value is above the mean. Generally Z-score value of -1.5 or less is considered indicative of a delay or deficit in the area measured, although this can vary, depending on the test. - T-score: Derived from the Z-score. 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. Age-equivalent Scores The age-equivalent score is the age at which the raw score is at the 50th percentile. 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 are indicators of test validity Construct-related validity: 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. Ways of establishing construct-related validity - Investigating how well a test discriminates among different groups of individuals, e.g age - Factor analysis: statistical analysis for determining a relationship between test items. - Repeated administration of a test before and after a period of intervention. Content-related validity: is the extent to which the items on a test accurately sample a behavior domain. For instance, to test self-care skills, it is impractical to ask a child to perform every conceivable self-care activity. A sample of self-care activities must be chosen for inclusion on the test, and conclusions can be drawn about the child’s abilities based on the selected items. Ways of establishing content-related validity - By review of the test content by experts in the field, who reach some agreement that the content is, in tact, representative of the behavioral domain to be measured. Criterion-related validity: is the ability of a test to predict how an individual performs on other measurements or activities. Ways of establishing 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. - Concurrent validity: describes how well test scores reflect current performance. - Predictive validity: identifies the relationship between a test given in the present and some measure of performance in the future. Understanding of all types of reliability Test-retest reliability Is a measure of stability of a test over time Obtained by giving the test to the same individual on two different occasions Pediatric test-retest evaluation the time span between administration must be short However must not be too close so the child can recall items administered (learning or practice effects) The correlation coefficient between the two test sections is the measure of test-retest reliability - Correlation coefficients are used in statistics to measure how strong a relationship is between two variables. Inter-rater Reliability The ability of two independent raters to obtain the same scores when scoring the same child simultaneously Often occurs by one examiner administer and score while the other rater observes and scores at the same time The correlation coefficient calculated from the 2 raters’ scores is the inter-rater reliability coefficient of the test Standard Error of Measurement 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 a number of times simultaneously, with no practice or fatigue effects, which is basically impossible making this a theoretical construct. It is an indicator of possible error variance in individual scores SEM is based on the standard deviation of the test and the tests reliability (usually test-retest reliability) Differentiate validity and reliability Validity: The extent to which the test measures what it claims to measure Reliability: is the extent to which a measurement is consistent and free of error Context of culture in assessments Tests developed primarily on a white, middle class population may not be valid when used with children from diverse cultural backgrounds It is important for examiners to be aware of the factors that may influence how children from diverse cultures perform on standardized tests For example, some children may not have any experience with testing and may not understand the spoken rules about test taking Some might not understand the importance of doing a task within the time limit or following the examiner’s instructions They may not be motivated to perform well on tests because the task itself has no intrinsic meaning to them The materials or activities may be seen as irrelevant, or the child, having had no experience with the kinds of materials being used in the tests, may not know how to interact with them Establishing rapport may be difficult either because of language barriers or because of a cultural mismatch between the child’s social interaction patterns and those of the examiner If the examiner is aware of these potential problems, steps can be taken to minimize possible difficulties Standardized tests should be used cautiously with children from diverse cultures OTs would find themselves frequently evaluating children from cultural or ethnic groups that are underrepresented in the normative samples of most standardized tests may want to consider developing “local norms” on frequently used instruments that reflect the typical patterns of performance among children of that culture Professional communication skills are essential when administering tests and reporting information  Laws, Policies, and Procedures Understand all relevant laws and application to practice IDEA, ESSA, Section 504, and ADA regulate many aspects of general and special education in public schools Public schools are generally funded through tax dollars and subsidized by state and federal funds. Public schools must comply with the regulations associated with these pieces of legislation to maintain their funding The Every Student Succeeds Act (ESSA) replaced No Child Left Behind (NCLB). ESSA continues to emphasize accountability, however, it allows local education agencies (LEA) establish their own accountability goals and monitoring systems, which may be less reliant on standardized assessments as a single measure of performance or improvement than a required under NCLB ESSA names occupational therapy practitioners “specialized instructional support personnel (SISP)” As SISP, OTs are expected to engage in conclusion with other personnel to support the academic achievement of students, participate in school wide systems of support, and to provide professional development training Students with disabilities who do not qualify for special education services under the IDEA may qualify for accommodations or modifications under Section 504 and under the ADA IDEA Part B IDEA was most recently reauthorized in 2004 and is sometimes referred to as the Individuals with Disabilities Education Improvement Act IDEA requires that states and public educational agencies provide free and appropriate education (FAPE) to children with disabilities in the LRE FAPE means that special education services must meet the standards of special education agency (SEA), be provided at public expense, be under public supervision and direction, include an appropriate education at all levels (preschool, elementary, and secondary levels), and be provided in accordance with the child's IEP Free means that the parents will no incur any costs associated with the services, beyond typical incidental fees that are charged to all students Appropriate, a term that is less objectively defined and means that children must receive the educational supports that adequately meet their unique needs LRE mandates that students with disabilities receive their educational program, including all their academic and related services with their nondisabledd peers to the maximum extent possible This does not guarantee that all students receive services within general education for the duration of the school day, rather the IEP team must consider general education as potentially meeting the student’s needs before moving to a more restrictive environment LRE should be applied to all students with a special needs, regardless of their disability IDEA states that the “removal of children with disabilities occurs only when the nature or severity of the disability of the child is such that education in regular classes with the use of supplementary aids and services can not be achieved satisfactorily Placement decisions should not be based on the availability of space or resources Depending on the child’s individual educational needs, students may receive supports and services in a variety of settings Most children with disabilities spend at least a portion of their day with their peers from general education However, some children with very significant disabilities may not be included peers from general education. When this is the case, it is up to the child’s IEP team to document the severity of the child’s educational needs and to articulate clearly why other, more inclusive settings are not adequate to meet them Removing a child entirely from the general education without the option for inclusion in at least some of the special classes (music and art class, and physical education) or nonacademic activities (lunch, recess) should be considered by the team as the LAST option Part B of IDEA specifies that an IEP must be designed to include special education and related services for all students from 3 to 21 years of age if it is determined by the educational team that the student requires such services to benefit from his or her public education According to Part B of IDEA, occupational therapy is considered a related service Related services are described as “such developmental, corrective, and other supportive services as are required to assist a child with a disability to benefit from special education” A student is eligible for special education under IDEA if he or she has a disability defined by one or more of these categories: intellectual disability, hearing impairment (including deafness), speech or language impairment, visual impairment (including blindness), serious emotional disturbance, orthopedic impairment, autism, TBI, another health impairment, specific learning disability, deaf-blindness, or multiple disabilities IDEA Part C Part C of IDEA is responsible for early intervention birth to 3 years old ADA Children with disabilities who qualify for special education are also automatically protected by Section 504 of the Rehabilitation Act of 1973 and under the Americans with Disabilities Act (ADA). All modifications that can be provided under Section 504 or the ADA can be provided under the IDEA if included in the student's IEP. Students with disabilities who do not qualify for special education services under the IDEA may qualify for accommodations or modifications under Section 504 and under the ADA ​Americans With Disabilities Act in 1990 prevents private and public sector employers, employment agencies and labor unions from discriminating against disabled applicants or employees.Considers someone disabled if he has either a physical or a mental disability that prevents him from partaking in at least one "major life activity," and who has a doctor's acknowledgment of the impairment. Section 504 A child with a disability who is not eligible for special education under IDEA may be eligible for services under section 504 of the rehabilitation act of 1973 Section 504 and Title II of the ADA complement IDEA to ensure nondiscrimination against children with disabilities in public schools Section 504 requires schools receiving federal funds to provide access to public education to students with documented disabilities The ADA ensures that the educational program is accessible to individuals with disabilities and may include providing specific modifications The definition of disability under section 504 and ADA is much broader than IDEA’s definition, therefore students who do not meet the criteria under IDEA, may be eligible for accommodations and other supports and services under section 504 Under Section 504 and ADA the definition of a disability is “a physical or mental impairment that substantially limits one or more major life activities, who has record of such an impairment, or is regarded as having such an impairment” Some examples include: mental illness, specific learning disabilities, ADHD, juvenile rheumatoid arthritis, cancer, diabetes, and hearing impairment Under 504, occupational therapy can be provided alone or in combination with other education services and may be provided directly to students as program supports to teachers working with students Students eligibility for Section 504 services are documented in guidelines developed by each SEA and LEA School personnel is not required to develop IEPs for students served under the Rehab Act, although a team at a minimum should develop written plan that states goals, services, and accommodations to meet those goals IEP Are based on the child’s present level of performance (PLOP) The Individualized Education Program (IEP) represents the formal planning process and resulting legal document that establish the services and programs that will enable the student to participate in school activities and receive an “appropriate education” The IEP is a written statement for each child with a disability that outlines the student’s educational and functional needs and the supports and services required to meet those needs IEP specifies the services to be provided and how often, (frequency, duration, location) Describes the student's present levels of performance and how the student's disabilities affect academic performance Specifies accommodations and modifications to be provided for the student Must be designed to meet the unique educational needs of that one child in the Least Restrictive Environment appropriate to the needs of that child The IEP team consists of the: - child’s parents - one regular education teacher - one special education teacher - a representative of the public agency who is authorized to make decisions on behalf of the agency - an individual who can interpret the instructional implications of the evaluation results - other individuals who have knowledge or special expertise regarding the child (related service personnel) - and as appropriate, the child Although related services personnel are generally considered “discretionary” team members, if an occupational therapist is formally identified as a member of the IEP or if occupational therapy is being discussed in the meeting, it is fitting and desirable that the OT attends the meeting Since occupational therapy is considered a related service, the IEP team determines whether or not occupational therapy services should be provided to a student based on the student’s educational needs and the OT’s recommendation Parents and students should participate in decision-making Parent’s have a “say” if the school and parents do not agree on the placement or services for the child Collaborative Planning IEP teams differ from other teams in the following ways: 1. There is a legal framework of required relationships among partners. Federal, state, and local laws and policies spell out in some detail who must participate and what they must do. This is especially true for the school district, which has many legal responsibilities regarding the education of students with disabilities  2. The team members share responsibility and accountability for the success of the student in meeting his or her goals The process is “results-oriented,” meaning that what matters is not how happy everyone is with the process, but the success of the student’s educational program The collaborative planning process involves many components: The first step involves the interpretation of the child’s most recent evaluation, consideration of the child’s performance on any general state or district wide assessments, and identification of the student’s strengths and needs through discussion with the parents, the students, and educational team members - This information is documented on the IEP and includes a description of how the student’s disability affects participation in general education The next step involves the development of measurable annual goals designed to enable the student to participate and make progress in the general education curriculum, - The goals are statements of measurable and attainable behaviors that students are expected to demonstrate within one year - At a minimum, a plan for measuring progress must be documented, specifying how the child is meeting IEP goals and when the periodic progress reports will be provided (should be as often as progress reports are given to parents with nondisabled students) - Occupational therapists are responsible for measuring annual goals and objectives when they are one of the services listed to support the student’s goal Goals in the education model Goal writing is a collaborative process completed at the IEP meeting with the input of all team members, including the parents and, in some cases, the student All team members must be knowledgeable about the classroom curriculum, behavioral expectations, and state educational standards Goal and target behaviors need to address academic achievement and functional performance, such as participating in physical education, writing an essay, eating lunch independently, playing with friends during recess, and participation in after school clubs The team may develop benchmarks that lead to annual goals The OT may think a goal is a priority for for a child, however, when viewing the whole child, the team may not agree If this occurs, some negotiation among the IEP team members may be needed to select priorities for the child so the appropriate goals and objectives can be developed for the student Program plan Once the IEP goals have been developed, the team determines the special education, related services, supplemental aid and services, modifications, and supports ot be provided by the school These pertain to the student’s advancement toward the annual goals, access to the general education curriculum, and participation in nonacademic and extracurricular activities across school environments The IEP team determines if related services are required to assist a child with a disability to benefit from special education Transition Planning Finally once the child turns 16 years old, or before if determined appropriate by the IEP team, the IEP must include a written transition plan The IEP team (including students and parents) develops the transition plan. The student must be invited to any IEP meeting where postsecondary goals and transition services are considered. Students as young as 14 are recommended to participate in transition activities, even if they do not have a formal transition plan. Transition is the process of beginning to plan for students completion of education and post graduation life The transition plan should include a statement of the services needed and should clearly connect the students goals for after school life and a planned course of studies in high school The transition services needed to assist the child in reaching those goals may include vocational training, supported employment, independent living, work experience, community participation, and planning appropriate High School classes in preparation for college When a child reaches age 16 a statement of interagency responsibility to support his or her transition is also included in the IEP IFSP Within 45 days of receiving the referral to early intervention, families and service providers participate in the development of an Individualized Family Service Plan (IFSP). The process of developing the IFSP includes creation of child- and family-specific goals, as well as identification of service providers who will support families to help achieve these goals. Once the process is complete, the IFSP serves as a document that guides the provision of early intervention services for the child and family. Development of the IFSP follows completion of the initial evaluation and assessment, on the basis of which eligibility for early intervention is determined and a plan for service provision is needed. The IFSP defines the environments in which the child is to receive services and provides a statement of justification if services are not provided in natural environments. The IFSP also specifies who the provider will be; the frequency, intensity, and duration of services; and the funding sources. Occupational therapists work closely with caregivers and professionals to develop the IFSP which includes goals and objects to measure progress. The IFSP is a map of the family’s services and informs everyone who will be working with the child and family about which services will be provided, where they will be provided, and who will provide them. The development of the IFSP occurs during a meeting facilitated by the service coordinator and attended by the family and at least one member of the evaluation team. It is a process in which professionals and families share information to assist the family in making decisions about the types of services that they believe will benefit them and the child. Occupational therapy intervention, as with other early intervention services, is based on identified concerns and expected outcomes in the IFSP. During the IFSP meeting, team members, including familidi ,scuss the findings from the multidisciplinary evaluation. The IFSP is a dynamic plan. To ensure that it meets the changing needs of the child and family, it is reviewed every 6 months or more often, if deemed necessary. Inclusion Inclusion is an issue of social justice and occupational therapists believe that children and youth with disabilities have a right to participate in all aspects of life with their typically developing peers, in schools and in the community. Therefore pediatric occupational therapists strive to provide integrated services in natural environments IDEA 1997 placed great emphasis on inclusion of students with disabilities in general education by embedding special and related services in the classroom and extracurricular activities when possible. The IDEA Amendments of 1997 also focused on student outcomes by requiring students with disabilities to be included in state- and district-wide assessments. Legal mandates such as IDEA (2005) require that services to children with disabilities be provided in environments with children who do not have disabilities. Services for infants and toddlers must be provided in “natural environments” and services for preschool and school-aged children must be provided in the “least restrictive environment.” Inclusion in natural environments or regular education classrooms succeeds only when specific supports and accommodations are provided to children with disabilities To support inclusion of children and youth with disabilities in natural environments, occupational therapists may recommend modifications to increase physical access, accommodations to increase social participation, or strategies to improve the child’s ability to meet the performance and behavioral expectations. Early Intervention Part C: Early Intervention (ages 0-3). States were given “seed” money to develop new comprehensive, interagency programs for infants and toddlers. Early refers to the critical period of a child’s development between birth and three years of age. Intervention refers to programs and services designed to enhance a child's development as a member of a family and support families in caring for their child. Early intervention describes services for children ages birth to 3 years who have an established risk, have a developmental delay, or are environmentally or biologically at risk. Early intervention programs serve several purposes, including enhancing the development of infants and toddlers with disabilities, minimizing their potential for development delay, and recognizing the significant brain development that occurs during a child’s first 3 years of life. Another goal of early intervention as defined in Part C of the IDEA is to enhance the capacity of families to meet the special needs of their infants and toddlers.  Contextual Components All contextual factors impacting children The HAAT model is a dynamic and interactive model in which three factors i the human, activity, and AT) form a collective whole that is placed within the context of participation. Participation includes four major areas; 1. Physical context which includes the natural and built surroundings and physical parameters 2. Social context refers to relationships and interactions with others 3. Cultural context consists of the child and family’s beliefs, values and customs 4. Institutional context includes broader social and cultural contexts that provide a legislative and moral behavioral framework. Ecocultural Framework The occupational therapist observes the student in his/her natural environment, which might include home, school (e.g., classroom, playground, lunchroom, bathroom, extracurricular areas), and community settings (eg., work settings or other relevant locations) The occupational therapist examines the environmental demands required for specific activities, given the child’s motor abilities and needs. The child’s preferences, interests, and motivations along with social, spiritual, cultural, and family factors (including finances) are examined as potential contributors to outcomes of AT interventions. Cultural factors that affect assistive technology (AT) delivery - Degree of importance attributed to independence - Values regarding health and wellness - Use of time - Sense of personal space - Values regarding finances - Importance of physical appearance - Roles within family, society - Adherence to traditions (family, culture, history) - Acceptable amount of assistance from others - View of healthcare Goal of universal design Ron Mace was a visionary who used the term universal design (UD) to describe the concept of making all products and the built environment physically pleasing and usable to the greatest extent possible by everyone, regardless of their age, ability, or status in life. According to the Center for Universal Design, “the intent of UD is to simplify life for everyone by making products, communications, and the built environment more usable by as many people as possible at little or no extra cost. UD is a proactive approach that eliminates many barriers but does not replace the need for individualized AT. National legislation prohibiting discrimination against people with disabilities the fair housing amendments act of 1988 and the Americans with Disabilities Act of 1990. The intent is to simplify life for everyone by making products, communications and the built environment more usable by as many people as possible at little or no extra cost. Assistive Technology – use, purpose, application Assistive technology: Any item, piece of equipment, or product system whether acquired commercially, off the shelf, modified, or customized that is used to increase, maintain, or improve functional capabilities of individuals with disabilities. Assistive technology enables people to live healthy, productive, independent, and dignified lives, and to participate in education, the labor market, and civic life. Assistive technology reduces the need for formal health and support services, long-term care, and the work of caregivers. Without assistive technology, people are often excluded, isolated, and locked into poverty, thereby increasing the impact of disease and disability on a person, their family, and society. Use of AT can create novel opportunities for children to explore, interact, and function in their environments. Introducing appropriate technology systems as early as possible enables the child with disabilities to participate in important learning situations that otherwise may not be possible. Role of assistive technology Occupational therapists use AT (also called adaptive equipment), such as reachers, buttonhooks, and pencil grips, to promote functional independence in children and youth. Judiciously selected AT affords children with creative solutions, which offers them greater independence and opportunities for participation at home, at school, in the workforce, in the community, and in society. AT devices and services can help a student improve, increase, or maintain performance of functional skills (e.g., self-help, mobility, or communication), access curriculum (e.g., multimedia presentations or books on tape), become a more efficient learner (e.g., pencil grips and raised lined paper to improve writing legibility), or compensate for lack of skills (e.g., word prediction software to assist with spelling or reduce keystrokes) AT can be instrumental in helping young children with disabilities learn valuable life skills such as social skills, (e.g., sharing and taking turns), communication skills, fine and gross motor skills, self-confidence, and independence. Appropriate interventions for settings e.g. difference in focus at a school vs. preschool vs. clinic Hospital or medical center: - Primary role is evaluation that is typically provided on an outpatient basis for a series of assessments (1-2 visits); may require a inpatient stay of 2-3 weeks - Referrals and recommendations made directly to agencies or third-party payers - Limited access to child for follow-up and training; limited opportunities to consult with parents and teachers - May provide direct treatment, particularly for children under the age of 3 years or those who have an acquired disability (e.g., spinal cord injury) Regional center: - Developed in response to legislation, funded by the Department of Education or other agencies for individuals with disabilities - Often has AT lending library for borrowing equipment on a short-term basis - Team has broad-based experience with various diagnoses, resources for obtaining equipment, types of AT, and adapted methods of use - Also involved in advocacy, consumer awareness, focus groups - Limited follow-up care and minimal input into training the child, family, and educational team Public school: - Most children receive AT services at a school - Daily problem-solving related to AT use can occur and child receives support in the natural environment in which AT is to be used - School-based team has easy access to chiId and understands educational curriculum but may lack expertise or experience with more complex AT systems Home and community setting: - May provide direct treatment, especially for children under the age of 3 years - Direct training available to child and family  - Problem-solving related to AT use can occur and child receives support in the natural environment in which AT is to be used - Can provide carryover to other practice settings such as school or work - May have limited opportunities to consult with others Facilitating classroom participation Examples of AT to support handwriting skills: - Text to speech - Electronic spell check - Picture-supported text or picture library - Abbreviated expansion - Word prediction - Electronic word and sentence bank - Voice recognition software AT Supports for Math: - Number line/ruler - TouchMath - Enlarged or masked math worksheets - Graph or grid paper - Alternative response methods - Handheld calculator - Talking calculator - Special features calculator - On-screen calculator - Specialized calculator Role of OT with overcoming barriers Consider AT devices and services as an integral and necessary part of the individualized education program (IEP) process as outlined by the Individuals with Disabilities Education Improvement Act. Become familiar with different types of AT and a variety of tools that support student needs. Assess each student’s need for devices and services to support educational, performance and access to curricular and extracurricular activities. Seek additional resources and assistance from other educational professionals such as the members of the IEP team. Gather and analyze data about a student and his or her customary educational environments, goals, and tasks when considering AT needs. Students communication, independent living, and organizational skills, along with demands of the task and environmental features, exist in a dynamic relationship and may all be considered in combination during the AT assessment process. Consider a range of AT options from no-tech to high-tech and use of existing resources, the procurement of new devices, or both. Organize the physical space where AT is used, establish routines that support use of AT, and support consistent use of AT in all appropriate environments. Communicate and document the AT process in the I EP, with rationale for the decisions made and scientific evidence to support devices and services. Evidence may include AT assessments, device trials, student achievement with and without AT, student-based preferences, and teacher observations.  Social and Emotional Development Characteristics of social engagement (birth – 3) Birth-6 months - Coos, then squeals - Smiles, laughs out loud - Expresses discomfort by crying - Communicates simple emotions through facial expressions 6-12 months - Shows special dependence on mother - May show stranger anxiety - Lifts arms to be picked up - Plays contentedly with other infants - Plays give and take - Responds playfully to mirror (laughs or makes faces) 12-18 months - Moves away from parent - Shares toys with parents - Responds to facial expressions of others 18-24 months - Expresses affection - Shows wide variety of emotions: fear, anger, sympathy, and joy - Can feel frustrated - Enjoys solitary play, such as coloring, building - Engages in parallel play - Laughs when someone does something silly 24-36 months - Cooperative play; takes turns at time - Shows interest in peers, enjoys having companions - Begins cooperative play and play in small groups - Shy with strangers, especially adults - Engages in dialog of a few words - Can be possessive of loved ones Psychosocial needs of school age children Social participation is important in the development of one’s identity. Adolescence is an especially important time for identity development. It includes defining who one is, what one values, and which directions to pursue in life. Identity development is a dynamic and individualized process that evolves throughout adolescence. In middle childhood (age 3 to 12), children become more competent and confident and more selective when choosing their friends. As they develop self-awareness, communication, and understanding of the thoughts and feelings of others, their social skills increase, and they improve their emotional control, which allows them to better fit in with groups and start to create interpersonal relationships. Friendships continue to change as children reach adolescence. They become more complex, more intimate, more strongly impacted by social context, and more significant to one’s psychological adjustment  Temperament and Attachment Children behave differently right from birth, along with culture, environment, and family. Temperament plays an important part in the development of personality. Temperamental Traits (9): 1) Activity Level: Ranges from low to high. 2) Biological rhythms: when a child eats, sleeps, and toilets may be regular or irregular. 3) Approach/Withdrawal: Some may be withdrawn while others are more approachable. 4) Adaptability: Some adapt quickly and some slowly. 5) Mood: Range from positive to negative. 6) Intensity of Reaction: Not reacting much to a fall or overreaction to sharing. 7) Sensitivity: to lights, noises, and touch. 8) Distractibility: Children differ in how distracted they are during activities. Can go from focusing only on one object to easily shifting attention. 9) Persistence: Some are not persistent, while others keep trying even when faced with difficulty. These indicators are messages the child is sending out. 3 Temperament Types: Flexible (Easy): Regular feeding and nap routines. Adaptable, easily toilet trained, cheerful, low intensity, and low sensitivity are traits associated with this type. Seldom make a fuss and can be taken advantage of by other children. Does not demand attention, but wants it. Caregiver checks in from time to time. Not usually a problem to caregivers. Easy and resilient causing the caregiver to give attention to other children. Fearful (shy, timid, slow to warm): When working with these children go slow. Slow to adapt and withdraw are the traits associated with this type. The caregiver should stay with the child to make sure behavior goes from cautious to enjoyment then step back. Caregivers will find themselves going through the frequency of pertaining to then stepping back. Assigning one caregiver to each child is important. Having their own special place such as a cubby, for them to be familiar with and get into a routine, will be beneficial. Feisty (Difficult, Fussy): Difficult for caregivers to handle. Active, intense, distract, sensitive, irregular, and moody are traits associated with this type. Caregivers should use redirection techniques, empathy followed by redirection of attention. Children won’t fit a schedule, so the key is to be flexible and adaptable as a caregiver. Resist being rushed. Constantly pushy and loud. The caregiver needs to remember the child is not always this way, when they are quiet help them see the value of the activity and make it special; also need opportunities to be active. Set up various areas for play for the child to go to throughout the day. Freedom lets the child be himself. Signs of attachment concerns in young children A child’s overall participation and performance in daily occupations is often judged based on the ability to be socially involved and interactive with others. Attachment to a primary caregiver influences social relationships and intimacy throughout life. Attachment to caregivers provides the child with an understanding of emotions and social relationships. Successful accomplishment of attachment in infancy results in a sense of security, and separation from the attachment figure leads to infant distress. Five patterns of attachment have been identified in infants: 1. A secure pattern that results from interactions with a caregiver who is sensitively responsive to the infant’s signals, reading them accurately and responding appropriately; 2. An anxious pattern characterized by clinginess or need for constant reassurance, related to a parent who is excessively protective; 3. An insecure-avoidant pattern of minimal emotional expression related to a less responsive, slightly rejecting caregiver; 4. An insecure-ambivalent pattern related to a caregiver who appears to be overinvolved, inconsistent, or neglectful in his or her responses to the child. 5. A disorganized pattern that results from parents who are intrusive, withdrawn, negative, or abusive  Vision and Visual Perception Cortical vision impairment The causes of visual impairments in children with CP may include but are not limited to, retinopathy of prematurity, congenital cataract, and cortical/cerebral visual impairment (CVI). Cortical visual impairment (CVI) is a decreased visual response due to a neurological problem affecting the visual part of the brain. Figure ground Figure-ground perception is the ability to perceive a form visually and to find this form hidden in a conglomerated ground or model. This ability enables children to differentiate between foreground or background forms and objects. It is the ability to separate essential data from distracting surrounding information and the ability to attend to one aspect of a visual field while perceiving it in relation to the rest of the field. Thus, children can attend to what is visually important. For example, children are visually able to find a favorite toy in a box filled with toys. Often, children who have difficulty recognizing words have difficulty in figure-ground perception Position in space The ability to perceive an object’s position in space relative to oneself and the direction in which it is turned. It is the discrimination of reversals and the rotations of figures. Co This perceptual ability is important in understanding directional language concepts, such as in, out, up, down, in front of, behind, between, left, and right. In addition, position in space perception provides the ability to differentiate among letters and sequences of letters in a word or a sentence. Object-focused spatial abilities, focuses on the spatial relations of objects irrespective of the individual. For example, children know how to place letters equal places apart and touching the line; they can also recognize the letters that extend below the line like p, q, y, g Form Constancy Is the recognition of forms and objects as the same in various environments, positions, and sizes. It is the ability to see a form and being able to find that form even though the form may be smaller, larger, rotated, reversed, or hidden. Form constancy helps children develop stability and consistency in the visual world. It enables children to recognize objects despite differences in orientation of detail. Form constancy enables children to make assumptions regarding the size of an object even though visual stimuli may vary under different circumstances. The visual image of an object in the distance is much smaller than the image of the same object at close range; yet, children know that the actual sizes are equivalent. For example, school-aged children can identify the letter A whether it is typed, written in manuscript, embedded in different words, or italicized.  Fine motor skills, Hand Development and Handwriting In hand manipulation In-hand manipulation involves: - Translation: linear movement of object in the hand from finger surface to palm or the palm to fingers. Types of translation: - Finger to palm: Object is held by distal finger surface, and the pad of thumb, and moved into palm. - Retrieving coins from a container - Hiding pennies in the hand (magic trick) - Picking up small pieces of food - Palm to finger translation: Objects are moved from an area of the palm out to the distal finger surface. - Move pennies from the palm out to the fingertips to feed a vending machine. - Move game pieces to place onto a game board - Shift: Child holds marker at midpoint and moves fingers downward towards writing end for placement prior to writing. - Turning pages in a book - Picking up sheets of paper - Separating play cards - Simple rotation: Marker is placed horizontally on a table with writing end at ulnar side of child’s hand; child picks up and rotates marker for writing. - Removing or putting on a small jar lid - Rotating a crayon or pencil - Removing crayons from the box and preparing for coloring Prerequisites for in hand manipulation - Activities involving general tactile awareness (easily repeated, generally not a skill challenge) - Using crazy Foam - Using shaving cream  - Applying hand lotion - Finger painting - Activities involving proprioceptive input (increases co contraction, strength, endurance; easily repeated) - Weight bearing (wheelbarrow walk, activities on a small ball) - Pushing heavy objects - Pulling (tug of war) - Pressing different parts of the hand into clay - Pushing fingers into clay or therapy putty - Pushing shapes out of perforated cardboard - Tearing open packages or boxes - Activities involving regulation of pressure - Rolling clay into a ball - Squeezing water out of a sponge or washcloth - Pushing snaps together - Activities involving tactile discrimination - Playing finger games and singing songs - Playing finger identification games - Discriminating among objects or textures by manipulating vision occluded Sequence of development of reach Reach 1. Exploratory (1-3 months) - Swipes at object, reach is inaccurate, infant combine reach and grasp 2. Perceptual learning/transitional stage (3-6 months) - Reaching becomes more accurate, becomes more direct, and the infant reaches to midline. By 6 months, combines reach and grasp with 2 hands 3. Skill achievement/adaptability and flexibility (6-9 months) - Reaches with one or two hands, accurate and direct reach; can change direction to reach midstream. By 8-9 months, infants can reach in all directions. Reach is smooth and efficient. Infant easily combines reach and grasp. Infant carries an object through space. Grasp 1. Exploratory (3-5 months) - First voluntary grasp begins 2-3 months. Infant squeezes the object with all fingers, and the thumb does not participate. Release is random, without voluntary control. Grasp is inefficient and an infant cannot move an object in his hand. 2. Perceptual learning/transitional stage (6-12 months) - Radial palmar and radial digital grasp patterns emerge. Infant actively uses the thumb to grasp objects. Infant is unable to move an object within his hands but can transfer hand to hand and explore in his mouth.  Voluntary re;ease begins at 6-7 months. Infant awkwardly grasps small objects. 3. Skill achievement/adaptability and flexibility (12 months-2 years) - By 12 months, the infant demonstrates a pincer grasp; this grasp is precise by 18 months. By 18 months, it demonstrates precision release. By 2 years, grasp is dynamic, allowing tool use; the child can use an object while holding it (toothbrush, spoon). Blended grasping patterns develop; the child can move an object while maintaining his grasp of the object. Development of Grasp (OPEN LAB) - Palmar (block is in palm of hand) - Intermediate (fingers holding block, but still using palm of hand) - Mature (three