Chapter 5 Community Paediatrics
Introduction
• Community paediatrics involves the assessment of children from neonatal age through to 19 years, with conditions ranging from specific foot problems to complex neurological conditions.
• It is important to have a basic knowledge of child development, milestones and normal movement patterns, knowledge of primitive reflexes and righting reactions.
• The assessment will require the selection of assessment techniques and knowledge that are used in other specialist areas, especially outpatients, orthopaedics, respiratory and neurology.
• To be effective the paediatric physiotherapist has to work with delicately balanced and integrated relationships between children/young people, their parents/carers, educational requirements, medical and therapy needs, personal objectives and anyone else involved in the management of the children.
• These may lead to areas of conflict, which will need to be managed through careful negotiation and all need to be included in planning the development of appropriate goals and functional outcomes, to enable individuals to meet their full potential.
Venues and appointment times
It is essential to choose a venue to work with children/young people that:
• Has suitable access for wheelchairs, buggies.
• Has a child friendly atmosphere.
• Ensures the safety of both child and therapist.
• Considers travelling distances for families and keeps them to a minimum.
There are a variety of venues a community therapist may work in:
• A children’s centre, nursery or play group.
• Mainstream school with or without resourced support from the local education authority (LEA).
• Some therapists may even consider working in a local gym or other community resources.
• It is also useful to consider the time that an appointment is offered to fit in with family commitments, such as work times for single parents, times other children may need support, e.g. collecting them from school or feeding a baby.
Consent
• Consent is essential, involving parental consent and also the consent of individuals.
• Therapists often need to consider inventive ways to explain the nature of their assessment and intervention and why it is important, especially to younger children and those with learning difficulties.
• Often a compromise is essential in order to achieve therapy which is effective and efficient, yet compliments the commitment that is made by children and/or those working with them.
• Therapy is often considered to be something that needs to happen 24 hours a day, 7 days a week, being taught and managed by a therapist, but implemented by many others.
• It is especially important to gain parental consent when planning to see a child in school with education staff.
• Children and adolescents often have very strong feelings and may make it clear they do not wish to participate in therapy programmes. It is therefore necessary to try to make treatment sessions fun, but also relevant to meeting set objectives.
• Children should be encouraged to take responsibility for their own therapy if this is possible.
• All health and social care organisations have guidelines or policies on consent. It is essential for any physiotherapist working in this field to familiarise themselves with these from the outset of the time they are working in community paediatric practice.
Child protection/safeguarding
• Child protection is very high on the agenda of everyone who works in paediatrics.
• Closely linked to nationally driven policies and procedures all health and social care organisations offer essential training to support therapists in this area.
• These are in place not just to protect children, but also to protect those working with them.
• There are many forms of abuse that children can be subjected to and a therapist working with children will often be the first to identify a possible problem.
• It is the responsibility of the individual to ensure that they attend child protection training as a priority to equip themselves with the knowledge to identify and handle these situations correctly.
• It is important to remember initiating a child protection procedure or a Common Assessment Framework (CAF) does not mean that children will be taken away from their families, very often it will flag up that a family needs help and identifies how it can be provided.
• All therapists are in a position of trust, but it is prudent that a physiotherapist does not put themselves into a situation where they are working alone with a child.
• As therapists we often handle children, ensure people know what you are going to do and why and if they find this unacceptable look for another way or even a completely different activity.
Manual handling and risk assessment
• It is an essential part of therapy practice to ensure the safety of those we work with and ourselves. All trusts have robust policies and procedures to ensure safe practice and it is an individual therapist’s responsibility to ensure that they attend patient handling training and relevant updates on a regular basis (CSP 2008).
• A risk assessment will need to be completed for any therapeutic handling procedure to ensure any risk to the health of the therapist or the child is reduced as far as is reasonably practicable.
Statements of special educational need
• For those children with a physical difficulty, integrating therapy programmes into many education settings can often be tricky.
• If a child has a statement of special educational needs (this is a legally binding document that requires the LEA to provide specific support over and above that provided for most children, in terms of extra finance and consideration of appropriate school placement) to support their passage through school.
• It is essential to ensure that a physiotherapy report is included within this.
• There will be opportunities to outline what a child is able to do and where and what kind of help they will need to develop physical and mobility skills in their school setting.
• If they are going to need postural support equipment in school this is the time to say so, pointing out when and for how long it should be used and who would be expected to pay for and maintain it.
• At this point the physiotherapist will be expected to say how much ‘hands on’ therapy support the child should expect to receive to meet their full potential.
• It must be pointed out that it may not be possible to provide the desired frequency of therapeutic input.
• Therapy and health issues are usually placed in part 5 of a child’s statement and cannot be challenged at an educational tribunal.
• If parents have issues with therapy provision as it stands in a statement they need to take this up with your organisation/trust.
• It must be realised that it is not the personal responsibility of the physiotherapist to provide what is outlined in the statement.
Physiotherapy in mainstream schools
• For most schools therapy is usually not a primary consideration.
• Often integrating this into a busy school curriculum is a real juggling act and gets harder the further a child progresses through the school system.
• It is surprisingly difficult to convince teachers that if a child has completed their physiotherapy programme they are more prepared and comfortable to apply themselves to learning.
• Another case needs to be made for placing the child in an appropriate piece of postural supporting equipment because this will enable the child to complete tasks more effectively and efficiently.
Physiotherapy in a school setting
• In a school setting it is relatively easy to integrate therapy into the fun learning situations which are created for younger children.
• Most education staff are happy to do so if you explain to them how and why.
• However with brighter children school staff often feel that time should be spent specifically on learning rather than on time-consuming therapy-related activities, however integrated they may be, especially as they grow older and school targets become more important.
• There are issues associated with placement in a nursery or school. These are wide ranging and will change as a child grows and expectations change.
• It is essential to provide specific training for staff and equipment to enable a child to be able to sit, stand, mobilise and function in a way that is not hazardous to themselves, other children or staff.
• As a child progresses through education there are issues of negotiating a larger building with dispersed classrooms on multiple levels.
• Appendices 5.1, 5.2 and 5.3 cover some of the commonly encountered issues in nurseries and in schools with suggestions for how these can be managed satisfactorily.
Assessment of the child
• It is helpful to be familiar with specific classification and assessment tools such as;
• These are useful once the main problems of the child have been established.
Please see chapter 1 for additional material on motor disorders
Referral process and preparation for the assessment
• Every community paediatric service will have a ‘new referral’ procedure and it is important to be familiar with this.
• Always check that the contact details on a referral are correct.
• If speaking to the family on the phone prior to the assessment confirm information such as;
• Explain what the assessment appointment will involve, give the parents your contact details and inform them how to cancel the appointment should it become necessary.
• Arrange a convenient appointment with the family; try not to see the child when it is due a sleep or is hungry as this is likely to affect willingness to cooperate and/or play.
• Before arranging to visit a child’s home it is essential to be familiar with the service-specific lone-working policy.
• Before assessing a child access other medical records and/or have a discussion with other professionals involved with the child.
• It is also useful to research any presenting diagnosis in order to be well informed during the assessment.
• On the day of the assessment ring or text to confirm that the child will be attending.
• Parents often find it difficult to remember the age that their child achieved various milestones.
• The ‘Personal Child Health Record’, often known as the red book, has pages for parents to record their child’s development and therefore it is useful if this is available during the assessment.
Environment
• When planning an assessment consider the best environment for the assessment to take place.
• The environments available to you will largely depend on where in the community the child is assessed, e.g. school (SEN/mainstream), home, health centre.
• Wherever the assessment takes place it is important that the environment is warm and safe.
• Privacy is important as the child/young person may have to be undressed or the parents/caregivers may disclose confidential information.
• Consider Health and Safety; is a hoist required, would a therapy couch or mat be most suitable, will space be required to observe walking, running, jumping?
Subjective assessment
Background information
• Obtaining a comprehensive history of the child’s condition and progress to date will ‘help’ you to decide how to proceed with your assessment.
• Some of the information required can often be obtained from previous records.
• Discussion with the parents/caregivers and child, if they have the cognitive ability, will provide an insight into the child’s general health, well-being and life skills.
• It will also establish expectations of the child, parents and school.
• Some questions may be upsetting for a family, especially if the assessment is before they have been given a reason for their child’s difficulties or if they are anxious about their child.
• It is important that the family/carers and child understand the questions; therefore they should be concise and relevant, avoiding jargon.
• An interpreter is recommended if either parent is not fluent in English.
• Before the assessment it is good practice to explain what will happen during the assessment and consent must be obtained before proceeding.
• Consent must be documented appropriately in accordance with local policies.
