The Environment of Pediatric Intervention:

Definition of Environment: describes both the physical and social settings in which
children develop, grow, and function. Examples: home, school, daycare, even structural conditions such as space, buildings, access, and equipment. This also can include the availability of materials such as books, toys, and games that foster learning and development.

The environment of pediatric PT is crucial to a positive intervention. Therapist's methods of PT usually focus around the medical model however in pediatrics therapy should focus on providing PT in the context of naturally occurring experiences or in the child's natural environment. When thinking about the environment there are four elements that need to be considered:

1. How aspects of the child's environment contribute to optimal or non optimal developmental outcomes.
2. How the family or the environment mediate change in the child.
3. Intervention programs/approaches that may influence the child indirectly through various caregivers.
4. The various types of intervention approaches that influence the child directly. (Campbell p. 879)

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Developmental Theories:

Transactional Theory: this theory views the child's development as an interaction between the child, family, and the environment, with all three areas having an equal power to change the child's development.

Ecologic Model of Human Development: This model has three different layers the family unit (microsystem), the neighborhood unit (mesosystem), and policy (macrosystem). In this model emphasizes both the multi-level and multi-faceted nature of environmental experiences that influence a child's development.

The Developmental "niche" this theory looks at the child's sociocultural environment. This theory as well has three components 1) the physical and social setting of a child's life 2) culturally regulated practices of child rearing/ child care 3) the psychology of the caretakers (Campbell p. 881-882).

This link takes you to the American Physical Therapy Association section on Pediatrics flyer on the importance of the environment in pediatric physical therapy. This handout explains the different types of environments and the importance in how each one can play a different role in a child's development. This flyer also has good suggestions on how physical therapists can implement therapy in a child's natural environment.

http://www.pediatricapta.org/consumer-patient-information/pdfs/Natural%20Env%20Fact%20Sheet.pdf

All the various environmental factors play a role in a child's development in different ways, so it is not to say that one domain is more important than another. Thus, it is important to form conceptual frameworks or models that can examine and cluster the factors to predict outcomes. The exchange between factors occurs in both the distal and proximal environments (Campbell p.881).



Distal Environment:

This may include geographic areas, such as regions, as well as communities with shared social goals and institutions. The way a child's development is influenced by his or her environment is directly related to the proximity of the environment. Thus, a distal environment has less influence on a young child's development. However, for a school-aged child, the influence of distal environments increases. In fact, research has shown that it may influence a child's outcomes more so than family factors.

As physical therapists, we have an emerging role in consulting families regarding various community-based opportunities for children, such as sports programs. We can consider interventions that offer informal support networks of family and friends who live nearby such as the Family Resources Scale and Network Survey. These are easy and family-centered ways of obtaining information on the environment from families (Campbell p. 883).

The Zero-to-three website offers a brochure that is a great resource for parents looking to choose a quality daycare for their child. It offers a checklist of items that match the child's individual learning style and personality to the type of setting that would be most optimal for their learning:
http://main.zerotothree.org/site/DocServer/match_care.pdf?docID=1021&AddInterest=1152&JServSessionIda004=45usbod691.app258d
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Proximal Environment:

This relates to the child's home environment, particularly to the child-caregiver relationship. In families with young children, the focus is on parenting behaviors and childrearing routines. How a child perceives and functions in this unit overlap into how a child will respond in other environments such as school and the neighborhood (Campbell p. 883-884).


A study done by Loraine Dunn (1993) supplements these findings. She compared proximal and distal features of a child's environment on their developmental outcomes, and some of her findings are worth noting. For example, she found that the distal environment (i.e., the child's day care setting) has more impact on his or her social development, whereas the proximal environment (family/home setting) has more impact on his or her cognitive development.
The following is a link to the article: http://cckm.ca/ChildCare/pdf/Dunn1993.pdf

Family Centered Care:

History of Family Centered Care

Family centered-care is a type of intervention that is now the basis of pediatric health care. This model was first introduced as the understanding of childhood development shifted from a hierarchical reflex model to a multi-systems model. The idea of the multi-systems model of development is that a child’s development is the result of the interaction of different systems that influence the child as a whole. One of those systems is family. Family-centered care focuses on the idea that the family needs to be involved in every aspect of the treatment of one of its members including planning and interventions (Tecklin, 1).

Family-centered care has also evolved overtime because the family structure has evolved. It has been reported that now only about 35% of the United States has a nuclear family structure (Tecklin, 1). Jan S. Tecklin reported in her book Pediatric Physical Therapy, 4th ed. that in 2000, it was also reported that the minority population grew from 20% o 31% and that 31.8 million of those people spoke a language other than English in their homes (1). These factors provide additional challenges, including limited resources and language barriers, towards the treatment of children with illness and disabilities. Because the United States is becoming more diverse, it is important to have a model of care that is individualized and ultimately directed by personal family beliefs and needs regarding health care (Campbell, 884-885).

Family-centered care is the foundation of pediatric physical therapy. Under this model, the therapist understands that the child is dependent on his or her caregiver and therefore they need to be directly involved in all of their interventions (Tecklin, 1-2). Physical therapy is now focused on teaching both the child and the caregiver interventions to ultimately make the child as independent and functional as possible with activities of daily living. Pediatric physical therapy has now shifted from only seeing kids in the clinic to getting involved in their natural environments, be it home or school (Campbell, 884,891). Tecklin also states in her book that ultimately, "the parents are the experts in caring for their children" (2). Therefore, interventions should be directed at helping them carry out that task successfully and independently rather than leaving the treatment up to the therapist alone.

Family Structure

Family structure is evolving with the times. There are new ideas about what the definition of family is. The nuclear family now makes up less than 50% of the United States' family structures (Tecklin, 1). Single parent families, dual families, same-sex parents, etc. are just a few examples of the different types of families out there. It is important to keep in mind as a therapist that the structure of a family can affect the amount of resources that are available to them. Also, Socioeconomic status, culture and belief can greatly affect a family's attitudes and reactions towards illness, disability and therapy. Cambell et al states in the book Physical Therapy for Children, 4th ed. that "overcrowding (i.e. large families) and limited resources has been associated with poor cognitive development, interpersonal behavior and mental health" (884). The authors also noted that "family structure can have a protective or stressful impact on child’s development or well being." During physical therapy assessments it is important to be aware of a child’s caregiver situation. It is also crucial to seek to understand the expectations the family has for the child’s functional independence (Campbell,884-885).
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Same sex parent families, nuclear families, single parent families are all examples of family structures (image ref. 9, 13)

Family Functioning

Campbell et al states that, "family functioning refers to the family’s ability to conduct and accomplish every day activities across various situations." The authors also explain that,"a child is a subsystem within the family system. The child influences and is influenced by the way the family performs its functions"(884-885). Research suggests that child-rearing and the behavior of parents has the greatest influence on the development of children socially, cognitively and emotionally. It is very apparent that parent-child interactions are the basis for future relationships a child may form. Research on motor development and parenting suggests that home environment and structure may have some affect on development (Campbell, 884-885).

As a therapist, it is important to understand the impact parent-child relationships and interactions can have on a child's development. Campbell et al explains that "when parent-child relationships provide nurture and responsiveness, the result is a healthy brain architecture, which can promote positive child outcomes." (885)
Not only a positive conversation can impact a child’s brain development but also simply showing up to a basketball game or cooking dinner and providing a comfortable home environment can make a difference.

Campbell et al cited Barnard's four features of successful parent-child interaction as follows:
  1. Repertoire of behaviors, such as body movements and facial expression
  2. Contingent responses to each other
  3. Rich interactive content in terms of play materials, positive affect and verbal stimulation
  4. Adaptive response patterns that accommodate the child’s emerging developmental skills
    (885)
    Health care providers can use these guidelines to create positive parent-child interactions when there is a limitation involved:

    limitation example: children with motor disabilities.
    intervention: educating families about disability, suggesting opportunities for participation and creating more interaction using the child's current strengths

Campbell et al also talks about how parent-child interactions require equal involvement of the parent and the child to be successful (885). In the study, The Effectiveness of Parent-child Interaction Therapy (PCIT) for Families of Children on the Autism Spectrum by Solomon et al, the parents in the intervention group using PCIT demonstrated a better understanding their child's disorder had a more positive perception of their children. The kids in the intervention group demonstrated increased adaptability to their normal environment (1767).

Another example of the benefits of parent-child interactions is the study performed by Spiker et al using video-taped recordings of mothers receiving weekly home visits and family centered based programs. Results were that mothers receiving weekly home visits with family-based care were more supportive and gave more appropriate stimulation to their children (Campbell, 885)

Campbell suggests that positive interactions include "flexibility of the caregiver, responsiveness to the child’s distress and cues, contingency in responses by both the child and caregiver" (886).

The following are defined by Campbell et al as "distinguishing features of successful and mutually enjoyable interactions":

1. Allow disruption 2. Redirect the child in a supportive manner 3. Allow the child to initiate an action
(886)

Campbell et al also provides a model therapists can share with parents called the "Teaching Loop" to enhance positive parent-child interactions when learning new tasks:

1. Verbally and nonverbally alerting the child to the task and teaching material
2. Giving clear instructions about how the task is to be performed
3. Allowing the child time to perform the task
4. Giving the child feedback
(Campbell, 886)

Culture

Campbell states that culture within the family can consist of "parenting behaviors and transcends beliefs and expectations about child development and societal roles". Culture and belief both contribute greatly to a family structure and how a family functions. It is important to be extremely familiar with a family's culture and belief system in order to give them proper family-centered care. Coming to a mutual agreement with family and caregivers about the proper health care a child needs while respecting a family's culture can be a challenging task. However, this is of utmost importance when using a family-centered care approach (Campbell, 886-887)

Culture is:
  • Considered to be a shared ideology and valued set of beliefs, norms, customs, and meanings evidenced in a way of life.
  • It influences how families might understand life processes, define health and illness, and perceive the cause of illnesses.
  • Culture will influence how flexible parents are to change, especially when it comes to new information or parent education (Campbell, 886).

Campbell argues that "conceptualizations of cultural environment and how it is linked to the developing child vary. Different types of beliefs influence how parents perceive and respond to children’s behavior" (887). As a provider, it is crucial to be cognizant of the fact that not every family is going to react the same to a child's illness or disability and, regardless of opinions, different cultural norms need to be respected while also advocating for the pediatric patient.

Different Types of Beliefs:
Categorical- associated with attributing a single cause to one outcome. Parents may exhibit difficulty in adapting their childrearing practices.
Compensatory- characterized by a belief that multiple causes lead to multiple outcomes. Parents are likely to pursue several childrearing options.
Perspective- associated with adaptive or flexible parents behaviors (Campbell, 887).

Parenting and Stress Coping

The difference between whether or not stress will disrupt family functioning is in how the family perceives the stressful event.
Types of Stress
  • Positive Stress- physiologic stress that is short-term and repairable
  • Tolerable Stress- can be neutralized by supportive relationships that provide a safe environment and have minimal impact on a child’s development.
  • Toxic Stress- can disrupt brain architecture, which can lead to developmental delays. Ex. Extreme poverty, physical/emotional abuse, maternal depression, family violence (Campbell 888).
PTs must exhibit good communication and observation skills to try and identify stressors in families. Once identified, the PT must take action such as making appropriate referrals (to social services or community resources) if needed. A good resource that has recommendations for how to minimize and cope with parenting stress is http://tlc.howstuffworks.com/family/deal-with-parenting-stress.htm.


Social and Professional Support (aka Informal and Formal)

For families with children with disabilities support can decrease stress and help the family function more efficiently. Support can play a role in the health and well-being of family members which overall, have a positive impact on the care for the child.
Social Support- mutually rewarding personal interactions from which an individual derives feelings of being valued and esteemed
Professional Support- information sharing (we are an important source!)

A study by Bailey et al. looked at outcomes for families of children with disabilities who participated in early intervention. Over 2500 parents were interviewed by phone by their child's third birthday. 85% of parents strongly agreed that these supports (referring to professional support) have allowed them to help their child grow, learn, and develop. 65% of parents strongly agreed that they now know how to work with professionals and advocate for what their child needs and that they know what to do if they feel their child is not getting good services. 57% of parents reported that their ability to work and play together as a family is pretty normal, even though their child has special needs (Bailey 1349).This study demonstrates that Part C early intervention (of the Individuals With Disabilities Education Act) provides supports that important for families with disabled children (Bailey 1351).

As stated by Gallagher et al, "greater social support has been found to be a strong predictor of better psychological adjustment" and health. This study looked at blood pressure of 35 parents parents who cared for children with disabilities versus the control group of 30 parents who had typical children. It was found that parents who cared for children with disabilities had higher blood pressure, spent more time caring for their children, and slept less. Out of these parents, "those that reported more social support, had lower blood pressure". (Gallagher 2104).

Social Support Theories:
Attribution theory- relates to motives for helping, the process of gaining or giving support, and the negative as well as positive aspects of support.
Coping theory- the cognitive aspects of support and its costs to those involved.
Equity theory- describes the reciprocal nature of support
Loneliness theory-emphasizes the effective aspects of support
Social-comparison theory- addresses the effects of peer support
Recommendations for interventions must involve: agreement between health profession and patient, understanding support can help decrease stress and prevent health disorders, and professions have a role in understanding sources of stress an proposing ideas for support (Campbell 890-891).
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Professional support can serve as the main source of information for parents (image ref 12)


Home Environment

As stated by Campbell et al and Iltus, there is a positive relationship between children's cognitive, social, and motor development and quality of the home environment. Iltus reported that a study done by National Institute for Child Health and Development (NICHD) stated that in "home environments which were more stimulating and well organized, children had better vocabularies, advanced attention and memory skills and got along better with peers" (Iltus 7).

HOME (Home Observation Measure of the Environment)- assesses various aspects of child participation in family activities, teaching and learning opportunities, and appropriateness of toys. Overall it assesses the "quality and quantity of stimulation and support available to a child in the home environment" (Sylva 25).
Here is an article by Vasiliki Totsika and Kathy Sylva that explains the HOME and gives examples of some of the components that may be used.

Examination and evaluation can lead to what should be focused on: for example either changing the child’s abilities, the task, the environment, or some combination to improve activity and participation (Campbell 891).
The Family and Parenting Institute outlines some recommendations for a good home environment to facilitate learning and cognitive development: http://www.familyandparenting.org/our_work/All-Other-Subjects/Early-Home-Learning-Matters/Practitioners-Section/Improvingoutcomes/What+is+a+good+early+home+learning+environment
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example of a great stimulating environment with many resources for children to learn (image ref. 8)


Implementing Family Centered Care as a Provider

The study "Incorporating patient and family-centered care into resident
education; approaches, benefits and challenges" by Philliber, I et al was designed to explore the challenges of implementing family centered care in the clinic as well as to create simple plans to overcome those challenges. Barriers emerged in areas regarding culture, environment, people, time, skills, and teaching and assessment. To overcome these barriers the participants of the study created two strategies to help implement family centered care into the resident and institutional environment.

Click on the figure below to see the strategies for implementing family-centered care into an institutional environment:

FIGURE 2

Team approach to services delivery

Contributions from "Team-based Service Delivery Approaches in Pediatric Practice" and "Team Processes and Team Care for Children with Developmental Disabilities."

Who does the team consist of?

  • Child
  • Parent(s)
  • Caregiver(s)
  • Other specialized experts (physicians, teachers, social workers, OT’s, PT’s, etc.)

Team will be composed of different combinations of members based on patient's particular needs

What is the role of the physical therapist in all team approaches?

  • Coordination
  • Communication and Documentation
  • Patient/Client-related instruction

What are the three Team-based approaches in Pediatric Practice?

1.) Multidisciplinary
  • Team member works independently, but obtains contributions from other team members.
  • Roles for the members are clearly defined.
  • Less frequent and less formal communication than with other approaches.
  • Involves individual goals

Overall: Each member functions within boundaries of own specific discipline


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2.) Interdisciplinary
  • Collaboration among team members for all aspects of the plan of care.
  • Roles for the members are less defined.
  • Greater amount of communication amongst team members.
  • Co-visits or group interventions are often performed.
  • Involves shared goals.

Overall: Group members collaborate as a team to create a plan of care, while also following through as a team during course of treatment


external image idg-team1.jpg?w=300&h=294


3.) Transdisciplinary
  • Involves a primary provider who interacts with the client regularly.
  • Primary provider receives consultation from other specialized experts.
  • Child’s and family’s current needs determine the specific primary provider and amount of consultation needed.
  • Primary provider may change based on families concerns.
  • “Role-release”- the sharing of knowledge across disciplines.
  • Involves shared goals and shared skills

Overall: Members go beyond their individual disciplines and develop new skills in different areas of expertise.

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Essential Elements of Teaming

Components of a Successful Team
  • Trust
  • Defined Roles/Responsibilities
  • Communication
  • Cultural Awareness
  • Teamwork
  • Common Goals
  • Consensus decision making
  • Goal oriented problem solving
  • Ongoing Evaluation
  • Leadership
  • Clarity
  • Commitment

The members' service delivery can take place in one area or several as long as collaboration and coordination exist

Recommended Practices

The Division of Early Childhood (DEC) recommends a transdisciplinary approach in early intervention settings. All three team-based approaches are on a continuum based on the amount and frequency of communication amongst team members.

Parent Resources


1.The World Health Organization website has useful information for parents. It has facts on early child brain development, risk factors, interventions, and economic impact.
http://www.who.int/en/

2.The American Academy of Pediatrics website is a reputable source with a variety of resources for parents.
www.aap.org

3.The Healthy Children website has a variety of links, including; ages & stages, healthy living, safety & prevention, family life, health issues, news, and tips & tools.
www.healthychildren.org

4.Zero to Three website guides parents in choosing quality child care.
www.zerotothree.org

5.This is a good website giving parents tips on how to cope with stress
http://tlc.howstuffworks.com/family/deal-with-parenting-stress.htm.

6.The Family and Parenting Institute outlines some recommendations for a good home environment to facilitate learning and cognitive development
http://www.familyandparenting.org/our_work/All-Other-Subjects/Early-Home-Learning-Matters/Practitioners-Section/Improvingoutcomes/What+is+a+good+early+home+learning+environment


Case summary-EVAN


Evan is a 18 month old boy who has been diagnosed with down syndrome. Initially we see Evan in his home environment. His mother describes him as a happy, playful, socially engaged boy. Currently his parents are struggling with feeding time due to Evan's inability to use a spoon to feed himself. For this reason Evan is currently receiving speech therapy. Evan is able to feed himself when eating finger foods however, has difficulty with any foods that require the use of a utensil. During the video we see the speech therapist teach Evans mom how to assist Evan at the elbow while using the spoon, in order to promote independence in feeding time. The speech therapist also worked with Evan on speech while using parent child interactions such as peek-a-boo. At daycare we see Evan interacting with children his age. However, Evan has some difficulties with standing and ambulation which prevents his participation in certain activities. Evan can participate in meal time and play but needs mod-max assistance to complete tasks that his peers would be able to complete independently or with minimal assistance. Evan has a very supportive environment at home and at daycare. All of Evan's caregivers work together to reach his individualized goals.
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References


1. "AAP.org." AAP.org. N.p., n.d. Web. 18 Sept. 2012. <http://www.aap.org/>.

2. "Accelerating Progress on Child Survival." WHO. N.p., 2012. Web. 18 Sept. 2012. <http://www.who.int/en/>.

3. Bailey, D. et al. Thirty-Six-Month Outcomes for Families of Children Who Have Disabilities and Participated in Early Intervention. Pediatrics. 2005;116;1346-52. http://pediatrics.aappublications.org.proxy.kumc.edu:2048/content/116/6/1346.full.pdf+html

4. Campbell, S., Orlin, M., & Palisano, R. (2012). Physical Therapy for Children (4th Ed.). P 882-884. St. Louis: Saunders Elsevier.

5. Dunn, L. (1993). Proximal and Distal Features of Day Care Quality and Children's Development. Early Childhood Research Quarterly. 8: 167-192.

6. Gagnon, Kendra, Elisa Kennedy, Lynn Jeffries, Lisa Chiarello, Mary Jane Rapport, and Sheree Chapman York. "Team-based Service Delivery Approaches in Pediatric Practice." Section on Pediatrics, APTA (2010): 1-4

7. Gallagher, S. et al. Social support is associated with blood pressure responses in parents caring for children with developmental disabilities. Research in Developmental Disabilities. (2010) 33; 2099-2105.

8. Iltus, Selim. "Significance of home environments as proxy indicators for early childhood care and education. United Nations Educational, Scientific, and Cultural Organization. 2006. 1-28.

9. "Little Tot Shop: Family Child Care". Image accessed Sept. 17, 2012 from http://littletotstop.com/

10. "Majority of American Support Gay Marriage". Image accessed Sept. 17, 2012 from http://blogs.babble.com/strollerderby/tag/same-sex-parents/

11. "New HealthyChildren E-Magazine!" HealthyChildren.org. American Academy of Pediatrics, 2012. Web. 18 Sept. 2012. <http://www.healthychildren.org/>.

12.Patel, Dilip R., Helen D. Pratt, and Neil D. Patel. "Team Processes and Team Care for Children with Developmental Disabilities." The Pediatric Clinics of North America 55.6 (2008): 1375-389. PubMed. Web. 18 Sept. 2012.

13. Phillibert, I. et al. Incorporating patient and family-centered care into resident education: approaches, beliefs and challenges. Journal of Graduate Medical Education. 2011 Jun 3(2);272-8. http://www.ncbi.nlm.nih.gov/pubmed/22655161

14. "Saturday Science". Accessed Sept. 17, 2012 from http://healthprofessions.missouri.edu/news/2011_saturday_science.php

15. "Single Parent Crisis". Image accessed Sept. 17, 2012 from http://www.todaysmodernfamily.com/index.php/5563

16. Section On Pediatrics . American Physical Therapy Association , 09 12 2012 . Web. 12 Sep 2012. <http://www.pediatricapta.org/>.

17. Solomon, M. et al. The effectiveness of parent-child therapy for families of children on the autism spectrum. Journal of Autism and Developmental Disorders. 2008 38(9): 1767-1776. http://www.springerlink.com/content/y2368v3w712550t2/.

18. Sylva,K. et al. The Home Observation for Measurement of the Environment Revisited. Child and Adolescent Mental Health. 2004;9;1. 25-35.

19. Tecklin, J.S. "Providing family centered care in pediatric physical therapy."(2008) Pediatric Physical Therapy (4th Ed.): 1-10.

20. ZERO TO THREE: Homepage. National Center for Infants, Toddlers and Families, 2012. Web. 18 Sept. 2012. <http://www.zerotothree.org/>.