Intervention Theories
Dyscovery Centre copyright 2009/10 Professor Amanda Kirby Not to be copied without permission
Different approaches to Intervention
Normative functional assessment -product orientated…. CO-OP approach General abilities approach- sensory motor, perceptuomotor-, SI Neurodevelopmental theory -milestones, sensorimotor functions.. Related to neurological markers.. No specified treatment Dynamical systems -specificity in learning, co-ordination dynamics..performance profiling, biomechanical, kinematic… task specific analysis Cognitive neuroscience– AB+D…. Motor screen/imagery, process orientated
....No man is an island, entire of itself
But part of a dynamic continuously interacting system
Bronfrenbrenner
Dynamic Systems theory
Development of the theory • Bernstein in 1967 – joints and muscles don’t work in isolation but movement is dependent on more variables • Thelen, Kelso, Newell, and Ulrich developed this further
Motor learning theories Traditional theories emphasise the role of the maturation of the central nervous system Dynamic systems theory emerged in the 1990s interaction between the developing CNS, the child's cognition, motor skills, motivation, experiences and biomechanics At each stage of the child’s development movement problems arise & CNS evolves dynamically to address them 8
Stages of learning Cognitive - understanding what is to be done – large variability, lots of errors Associative - has found the most effective way of doing the task, begins to make more subtle adjustments – fewer errors Automatic - performs easily
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Practice Single most important variable is the amount of appropriate practice Random versus blocked Random superior for retention & transfer Blocked leads to improved performance on an immediate basis
Part or whole task Most complex tasks should be practiced as whole tasks as it is the problem solving activity engaged in by the learner that contributes to how well the skill is learnt
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Types of feedback Intrinsic – inherent within the task and is received from child’s sensory systems through normal movement Extrinsic – provided by other person or by observing the results of one’s action
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A child’s behaviour and actions will be altered/effected by their • Environment • • • • •
Attitudes Demands Parents Nutritional status Others behaviour
• Tasks • Individual attributes
How does this work?
Success is dependent on a number of variables Size of the ball
Size of the child
Dis
e c n ta
y a aw
he t from
d l i h c
Speed of the ball
Ability of the thrower
Example
A child having difficulties copying down information from a whiteboard WHY?
en p e
h t Ha s k n i no
Pain in a hand
Can th
e ch
ild s
ee
Too much to remember Is the chair too low
Is
the
elb Is the inform ow ation un being sta given ble too fa s t? Is there too much noise to hear what to copy
Approaches to intervention
Deficit orientated ◦ Sensory integration ( Ayres)
◦ Sensorimotor approaches (Ayres, Bobath, Frostig)
◦ Process orienatated ( kinaesthesia- Laszlo and Bairstow)
Performance orientated ◦ Task based approaches ( Schoemaker)
◦ Cognitive approaches ( Polatajko, Sugden and Henderson)
Task-orientated Task Fun
Practice
Variety
Graded approach
Child and parent lead
Motivation
Self-esteem
Positive experiences
(research is suggesting that this approach is more successful)
Task specific Child works on specific task while also learning underlying movement principles (implicit learning) that may transfer to other related tasks Acknowledges the unique set of movement skills required for a particular task The child is given the opportunity to practice the task Clinician uses skills of task analysis, modification and adaptation to enable the child to achieve the task Beneficial to children with DCD if conducted 3 to 5 times a week in a group or home setting. Pless & Carlsson 2000 20
Cognitive motor approach Emphasis on child performing functional tasks in everyday life settings Movement competence is a problem solving exercise involving action planning, execution & evaluation Interaction of cognitive, affective & motor competencies Derived from motor learning & motor development literature
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Cognitive motor approach 31 children aged 7-9 years. Individual profile guidelines for teachers & parents. 3-4 sessions/week lasting 20 minutes approx. 27/31 children showed significant improvement in their motor skills Sugden & Chambers 2003
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Ecological intervention Task approach with a difference - tasks are taught either in groups of classes of tasks or the same task is taught in loads of different situations both addressing the solving a movement problem issue and generalisation
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Ecological intervention Intervention outcomes are a function of the interaction between child’s resources, environmental context & manner of presentation of tasks Based in ecology of child’s life – family, school, professionals involved Functional tasks 24
Motor Development and Learning Resources of the Child
Outcomes Environment in which Activity occurs
Manner of presentation
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Ecological intervention Tasks taught in groups representing classes of activities to facilitate generalisation Consider the child’s wishes & priorities Involve a number of individuals – parents, teachers, health professionals Evidence based & grounded in theories applicable to DCD
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CO-OP Client centred approach focused on strategy based skill acquisition 4 objectives skill acquisition (primary aim) cognitive strategy use generalisation transfer Early evidence suggests this is an effective approach to improving functional performance in children with DCD 27
Family centred functional therapy Family-centred functional therapy (FCFT) has been developed by the McMaster team in Canada. FCFT is based on concepts from family centred services and uses a systems approach to motor development. Addresses not just the individual capacities of the child but considers the task and environment as potential vehicles for change. It is still an emerging clinical model for children and so far has only been applied to children with cerebral palsy 28
4 clinical principles Promoting functional performance 2. Identifying periods of change 3. Identifying and changing the primary constraints in the task, child and/or environment that prevent achievement of the task 4. Encouraging practice 1.
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From motivational theories CA R E Develop Competence Provide opportunity for Autonomy Promote positive adult peer Relationships Maximise Enjoyment and minimise anxiety
Develop competence
Optimally challenging activities ◦ Match the activity to the child ◦ Modify the equipment and rules ◦ Frame simple goals
Create mastery motivational climate ◦ ◦ ◦ ◦
Focus on effort Learning Skill mastery Realistic goals
Provide appropriate praise, encouragement and instruction ◦ Participation and effort ◦ Mastery attempts and achieving goals
Opportunity for autonomy
Provide opportunity for a variety of activities ◦ Menu of structured and unstructured ◦ In and outside ◦ Allow for activity choices ◦ Help children help themselves- self regulation strategies e.g. think aloud
Promote positive relationships Feel connected with peers/adults Structured after school programmes Promote social relationships Parents acting as role models
Maximise enjoyment
Individual or group? Individual – tailored to specific needs of the child but ? Context. Also resource intense Group harder to tailor to individual but peer group benefits & resource efficient. Opportunity for children to meet others like them, can run parent groups alongside
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Motivation
What else is there to think about? • • • • • • •
Whole child- 24 hours Times of transition Future needs/skill demands Self esteem Social opportunities What is the prime problem at this time... What may be a problem in the next 5 years
Goal based intervention & evaluation
Why use a goal focussed approach? • Child and family centred approach – – Decision making in collaborative partnership between parents & professionals, reflecting family rather than therapist goals – Children want a voice in decisions made about their health • Social model of disability – – International Classification of Disability WHO • Evidence supports an ecological approach which considers the dynamic interaction between child, task and environment
What is a goal? • A behavioural statement of what the child is expected to complete or perform • A criterion that states how the behaviour will be measured • Conditions for performance of stated behaviour
What are appropriate goals for therapy? • Goals that have meaning for the child and family • Goals that are achievable • Goals that are supported by current level of knowledge – evidence base • Goals that fall within the specific role of the professional working with the child
Some comments from Anita Bundy • Therapy should provide experiences through which children grow into themselves • OT enables people to do what they want in everyday life • Help parents be effective – consultation with parents important & beyond OT/PT skills • Coach don’t direct • Positive helping relationships – be helpful in minimising difficulties • It is all about imagining possibilities
Goals should be • • • • •
Specific Measurable Attainable Realistic Time limited
Goal setting • Social model of disability focuses on the impact of the condition not the impairment • Therapy aims to reduce the impact on activities of daily living/occupations NOT to change the impairment • Child & family focussed NOT therapist’s goals • Ecological intervention
Goal orientated assessments • Perceived Efficacy & Goal Setting System (PEGS) 24 items 5-10 years • Picture Activity Card Sort (PACS): 75 cards depicting personal care, school/productivity, hobbies/social activities, sports. 5-14 years • Child Occupational Self Assessment (COSA) 25 items 7/8 years+ • Children's Assessment of Participation and Enjoyment (CAPE) 55 items 6-21 years
• Preferences for Activities of Children (PAC) 55 items 6-21 years • Pediatric Evaluation of Disability Inventory (PEDI) – 6 months – 7.5 yr • School Function Assessment (SFA) - 411 yr • Canadian Occupational Performance Measure (COPM) – from 9 years of age with child
• School Assessment of Motor & Process Skills (School AMPS) –
Setting goals: PEGS & COPM • Do PEGS with child • Explain to parent/carer that you are going to use child’s goals for therapy • Ask parent if they want to add goals • Negotiate and agree goals with child & parent/carer • Do COPM – score importance, performance & satisfaction
From goals to intervention plans
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Intervention approaches Practicing what you can’t do Doing what you want to do Doing what you need to do Avoiding what is difficult and is likely to persist Seeking out strengths
Approaches to support How much time have you got What is important for now What is important for the future Listening to the child Practising enough
Intervention The same goal may be achieved in a number of different ways • Modify the task • Change the environment • Change the child’s skills/abilities
Equal or greater focus on changing environments & tasks rather than skills
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Action requirements Envi ron men tal dem and s
Neither body transport nor object manipulation
Object manipulation only
Body transport only
Both body transport and object manipulation
Neither regulatory variability nor context variable
Maintaining standing balance
Writing on a blackboard
Walking on a Walking on a pavement pavement while pulling along a bag on wheels
Context variable only
Using sign language
Dealing a deck of cards
Playing hopscotch
Regulatory variable
Standing on a moving escalator
Standing in place when dribbling a ball
Walking on a Dribbling a moving ball while escalator running
Both regulatory variability and context variability
Balancing on alternate feet on a moving escalator
Playing a computer game with a joy stick
Running through a crowded airport
Twirling baton while doing gymnastics
Dribbling a ball while running and defending
Tasks Self care: dressing (laces, buttons, zips, quicker), cutlery, bottom wiping Productivity: finishing work on time, writing neatly, scissors Play & leisure: riding a bike, playing games & sports, running, skipping
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Environment & presentation Safe Space Peer group Start with easy tasks Praise effort & participation Belief that child can achieve task
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M.A.T.C.H. the activity to the child
Modify the task Alter your expectations Teach strategies Change the environment Help by understanding M.A.T.C.H. strategies available from CanChild website http://www.canchild.ca/
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M.A.T.C.H. Difficulty keeping up with handwriting, slow, incomplete work, crucial information missed, unable to listen and take notes simultaneously, complains of hand being tired
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M.A.T.C.H. strategies Reduce amount of writing required Ensure all written output is necessary – ask yourself “What skill is this demonstrating to me?� Minimise time spent copying non-essentials (e.g. date, title) Allow rough and final drafts on computer Photocopy notes from class and teach child how to pick out key meanings while peers are copying from board Allow more time to complete work If encouraging speed, accept a less accurate product (and vice versa) Let child use technology 57
Handwriting Observe pupil writing Pencil grip, sitting position, letter formation Look at handwriting Letter size, spacing, on the line Discuss with pupil Do they want writing to be different, does their hand ache
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Pencil grips Dynamic tripod
Lateral tripod
Dynamic quadropod
Lateral quadropod 59
Sitting position Bottom back in chair, table at elbow height, feet on floor, non-writing hand on paper. Sloping desk may help.
Letter formation, start & finish, size, shape Teach in letter groups c a d g o q, b h n p m r, w x z k, e s f, i t l, u y j
Letter joins – need to be taught 4 basic joins ai, ou ab, ol
Speed Trade off between speed and legibility, different writing for different tasks, exam techniques 60
Set goals together Talk positively about improving handwriting Explain changing handwriting not easy and changes not immediate Reassure pupil that short (7-10 minutes a day) can make a difference Make decisions about problems and solutions together Set priorities and work on 1 problem at a time 61
M.A.T.C.H. Messy/disorganised desk or tray Ensure time between activities to put things away Provide visual clues/labelling to help with effective use of space (e.g. for pencils or notebooks) Use colour coded workbooks Timetable weekly desk/tray cleaning time Teach child how to organise desk/tray Minimise what children keep in their desk/tray
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M.A.T.C.H. - Poor at PE Use large balls, under inflated balls, balloons, bean bags When a new skill can be taught using hand-over-hand instruction consider demonstrating with child with DCD so they can feel movement and get 1:1 practice first Encourage self and peer evaluation regarding participation and effort Emphasise fun, participation, fitness rather than proficiency Allow child to chose non-competitive games when possible Put children with similar abilities together to work on new skills Be aware of safety risk to a child with poor coordination
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Management of DCD
Whole school
THE APPROACH GENERAL SUPPORT
SPECIFIC SUPPORT FOR AN AREA
INDIVIDUALISED SUPPORT Referral for further guidance
Strategy
Whole authority School Classroom Child
Whole school Wave 1 Whole school policy ◦ ◦ ◦ ◦ ◦ ◦
Inclusive teaching Liaison with home and school Transition planning PE strategy Flexible recording /writing schema Awareness of overlap in Splds and general awareness of conditions ◦ Social opportunities
Wave 2-short focused intervention
Screening to gather further information Key pupil into topic work Model Target skills development and provide scaffolding and training Check language understanding as well
Wave 3 individual
IEP- focused on specific areas Organisational skills development Ball skills/balance Handwriting /recording/ICT Social and communication support
The challenge to move towards a social model of disability from a medical model
The need to provide for adolescents and adults AND NOT just children In order to learn from their outcomes and to influence intervention at all stages
Changing and continuing needs in adults with DCD 2/3rds still had motor difficulties 50% still had handwriting difficulties 50% had organisation/time management
Start with a universal design Principle One: Equitable Use – Provide the same means of use for all users: identical whenever possible; equivalent when not. – Avoid segregating or stigmatizing any users. – Provisions for privacy, security, and safety should be equally available to all users. – Make the design appealing to all users The Dyscovery Centre copyright 2008
Principle Two: Flexibility in Use • Provide choice in methods of use e.g. giving information- CD, Paper, online, tape • Accommodate right- or left-handed access and use- keyboard, scissors, placement • Facilitate the user's accuracy and precision • Provide adaptability to the user's pace. The Dyscovery Centre copyright 2008
Principle Three: simple and intuitive • Eliminate unnecessary complexityprocesses/forms/files/assignments • Be consistent with user expectations and intuition. • Accommodate a wide range of literacy and language skills. • Arrange information consistent with its importance. • Provide effective prompting and feedback during and after task completion. The Dyscovery Centre copyright 2008
Principle Four: Perceptible Information • Use different modes (pictorial, verbal, tactile) for redundant presentation of essential information. • Provide adequate contrast between essential information and its surroundings. • Maximize "legibility" of essential information. • Differentiate elements in ways that can be described (i.e., make it easy to give instructions or directions). • Provide compatibility with a variety of techniques or devices used by people with sensory limitations. ( e.g. screen reader) The Dyscovery Centre copyright 2008
Principle Five: Tolerance for Error • Arrange elements to minimize hazards and errors • Provide warnings of hazards and errors. • Provide fail safe features. • Discourage unconscious action in tasks that require vigilance- using idioms, terminology • Think about this also in social terms- too much noise/too big a group/not understanding terms used…….. The Dyscovery Centre copyright 2008
Principle Six: Low Physical Effort • Allow user to maintain a neutral body position. ( seating in class- desks and chairs) • Minimize repetitive actions. • Minimize sustained physical effort – recording,sitting still, carrying, lifting.
The Dyscovery Centre copyright 2008
Principle Seven: Size and Space for Approach and Use • Provide a clear line of sight to important elements for any seated or standing user. • Make reach to all components comfortable for any seated or standing user. • Accommodate variations in hand and grip size. • Provide adequate space for the use of assistive devices or personal assistance. The Dyscovery Centre copyright 2008
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