Chapter 5 Community Paediatrics
The development of the child
• A physiotherapist working in paediatrics should have an awareness of the stages that infants and young children progress through during their development.
• The physiotherapist may identify issues associated with motor function or the presence of a visual or hearing impediment.
• The physiotherapist should also be aware of the levels of development achieved by children and what would normally be expected in order to assist the planning of treatment interventions.
Locomotor development development
• The development of a child will include their ability to move independently, use their hands and to be able to interact with their environment through the use of their senses of vision, hearing and cognition.
• Most children follow a regular pathway of development, during which the different stages may be reached at different times.
• The presence of impairments such as vision or hearing or premature birth may lead to delay in or even failure to achieve certain developmental milestones.
• The major milestones for infants involve sitting independently (6–11 months), crawling (6–12 months), independent walking (18 months).
• Some children miss out the crawling stage and move on to standing and walking from sitting, if the walking is achieved later, e.g. 20–24 months, then this may be indicative of a child with low tone or of developmental delay.
• Children begin grasping objects during their first year, initially with both hands and then with one.
• The grasp begins to become more dextrous with sufficient precision being developed to build a column of blocks by the end the first year and hold a pencil by the age of 3.
Speech development
• The earliest signs of communication occur when a child begins to point to objects (9–18 months).
• Between 9 months and 1 year children will begin to show understanding of simple words and sentences.
• During the second year the number of recognisable words increases so that by 3 the child will be able to distinguish between something being in or on something.
• Most children will be able to combine multiple words by the second year.
• Fluency in speech occurs by 4 years although when angry or excited they may stammer during their speech.
Hearing
• Infants react to sound from birth, by turning their eyes in the direction of the sound.
• By 4 months the child will turn towards the sound.
• By 7 months once sitting ability has developed the child will turn directly towards their parent or carer.
• A hearing impairment is often missed unless it is profound and identified by the child’s parents.
Vision
• Infants will turn their head towards light and from 1–3 months an infant will fix on a parent’s face and follow their own hand movements. By nine months they are able to see and poke small objects such as crumbs. By one year they will watch objects such as birds in a garden or a car passing by.
• The concerns of parents may help to discover impending problems, e.g. inability to fix vision.
• Potential vision issues in small children need to be assessed by an appropriately trained professional (Frost & Sharma 1997).
The management of children with neuromuscular disorders
• Duchenne muscular dystrophy is one of the commonest inherited diseases found in children and as a consequence physiotherapists working in community paediatrics will encounter these children in their practice.
• The role of the community physiotherapist is primarily to monitor those children who are at risk of developing debilitating contractures in the hips and around the ankles when the child is able to walk and then progressively in the remaining limb joints once the child becomes wheelchair-dependent.
• The physiotherapist will be responsible for teaching the parents/carers and school staff how to stretch the tendo-Achilles to maintain range of dorsiflexion and hip flexion in order to maintain range necessary for independent gait to be maintained.
• These will need to be carried out on a daily basis and the presence of contracture monitored carefully.
• Night splints should be provided to maintain the ankle in dorsiflexion at night and these tend to be ankle foot orthoses (AFOs).
• The physiotherapist should encourage regular, moderate amounts of active exercise in order to maintain joint motion, avoiding the use of resisted exercises.
• Aquatic physiotherapy will benefit these children, enabling joint motion to be maintained as the child has fun in the water.
• As the child shows signs of losing the ability to walk the physiotherapist will need to ensure that the child is referred to a specialist centre for the provision of knee ankle foot orthoses (KAFOs) and possible release of tendons such as the Achilles to facilitate joint motion compatible with achieving independent gait.
• The longer the child can remain able to walk the later they will develop the impending spinal scoliosis associated with constant wheelchair use.
• Once the child has been provided with KAFOs the physiotherapist in the community will be monitoring the ability of the child to maintain the ability to walk.
• With the loss of walking ability the child will need to be taught wheelchair skills.
• At this stage skin care will become important and will need to be reinforced with the child, parents/carers and school staff.
• Spinal posture will have an adverse effect on respiratory function and spinal jackets will need to be provided to prevent the deterioration of the spinal posture. At this stage the child will be monitored by the specialist centre for the need to operate to maintain the spinal posture (Eagle 2007).
• The reader is referred to the acute paediatric chapter in this volume for further detail regarding the management of neuromuscular disorders.
The management of children with musculoskeletal disorders
• Children will present with a wide range of musculoskeletal disorders, which may be managed by the physiotherapist in the school or home environment, however, there will be situations where a child may present with a problem or a condition that is beyond the competence of the community physiotherapist.
• In these cases it is important to liaise with musculoskeletal specialists either in the community or in the nearest specialist centre.
• The community physiotherapist should draw on their core knowledge and skills to manage children with musculoskeletal dysfunction.
• The reader is referred to the section covering the management of musculoskeletal disorders in the acute paediatric chapter in this volume for further detailed information on the treatment modalities and approaches that can be used.
The management of children with neurological disorders
• Successful treatment of children with long-term neurological conditions will be dependent on the physiotherapist having an effective working relationship with the child’s family and/or relatives or alternative carers.
• Physiotherapy treatment will be ongoing, often for the whole of childhood, but despite the amount of physiotherapy involvement it is the people who are with the child the most who will have the greatest impact on their development.
• A child may be referred for physiotherapy at different stages of the medical pathway, for example a child born prematurely or perhaps into a socially deprived environment where there is a high incidence of morbidity or alternatively where health and social care issues have already been identified, will ideally be referred to a number of community services on discharge from hospital.
• Many children will be referred later, with or without a diagnosis, with parents being aware or potentially unaware of their problems.
• The timing of the referral can impact on the relationship the family have with the physiotherapist. For example, does the family want the input, do they know their child has problems? Are they still in the stage of denial?
• Often the child’s problems are not isolated. An initial need for physiotherapy intervention may sooner or later develop into the need for many other professionals and services to become involved in the child’s management.
• Children with a disability often have a huge multidisciplinary team around them and reliable inter-professional communication is vital. Physiotherapists need to prioritise their time and establish which meetings or clinical appointments they should attend.
• The purpose of attending a meeting may be to provide or to obtain information, but it needs to be considered that both can be achieved through the provision of reports, emails, letters, and phone calls if necessary.
• The physiotherapist may find themselves the health representative within an educational setting or a child’s advocate during a hospital clinic appointment.
The physiotherapist and their relationship with parents/carers
Developing respect and confidence
• The parents or carers are usually the most important people in a child’s life, and therefore it is essential that they are able to respect and have confidence in their child’s physiotherapist.
• There is a strong possibility that a physiotherapist will be working with a child and his or her family for a number of years, therefore the physiotherapist must strive to ensure that there is a positive working relationship.
• It is not trite to say, that the parents need to like their child’s therapist.
• Setting up good early relationships is vital; it helps if the child doesn’t cry every time that the physiotherapist pays a visit too!
• Some basic organisational details are crucial to getting off to a good start. Setting appointments at a time that is convenient for the family.
• Arriving for appointments at a previously agreed time.
• Setting up communication channels, whether via email or phone.
• Giving the parents/carers confidence that you are easily contactable and will return calls within a relevant time period are all small details that are key to developing a good effective working relationship with the child’s family or carers.
• As with any service there must be access to interpreters and written information sheets or leaflets explaining what physiotherapy intervention entails, and what is to be provided by the therapist, and in turn what is expected of the family and other settings in providing the physiotherapy programme.
• Information must be presented in a way that is appropriate for the recipient and is respectful of the cultural or religious beliefs of the family or carers.
Skills required by the therapist
Working with the multidisciplinary team
• Within a paediatric setting, the medical team is extended to include education, parents, carers, social teams.
• Children with disabilities may often require a high number of interventions and support and within the school setting ‘Statementing’ is in place to enable the child to receive the support required to access and achieve an education.
• The Common Assessment Framework (CAF) and Team Around The Child (TAC) are used by education, health and social teams to assess a child’s overall needs.
• CAF and TAC are also used when there are concerns about a child if they are considered to be at risk.
• This system is available to any child whether they have disabilities or not.
• The child and family may require support to deal with many issues, e.g. the family may need some respite care for their child to provide time for them to deal with family life.
• Respite care is often quite limited, but may consist of some hours per week, or a day or overnight stay in hospice or supportive accommodation.
• The therapist may need to liaise with respite care in order to teach a number of people how to carry out the child’s physiotherapy or 24-hour positioning programme.
• Physiotherapy reports need to be both succinct and timely as they may provide a paediatrician or orthopaedic consultant with information about how a child is progressing, or not.
• Educational support for children under the age of 5 years can vary.
• Some areas may have a system called Portage, where an LEA (local education authority) employee visits the family at home to help with the child’s development.
• Social services (renamed as children and families teams) have systems that oversee a child’s safety and support children with disabilities to the extent of recommendations for housing adaptations.
Following the assessment
Goal setting
• When the assessment process has been completed the physiotherapist will formulate a problem list and in conjunction with the child and/or parents/carers set objectives for treatment. This should ensure that all parties understand the issues and the plan for managing these in the short and long term.
• It is critical to achieving a successful outcome that the child and the family have ownership of the objectives and enter freely into a contract with their physiotherapist.
• This should ensure that the child and their family or carers have a good understanding about exactly what their commitment needs to be.
• The physiotherapist will assess the child with a view to this being an ongoing process that evaluates the specific needs and enables the modification of treatment as indicated by the assessment findings. This should ensure that the treatments plan is successful and the goals are achieved.
• Each treatment session should effect a change in the child; if it does not achieve the desired outcome then this indicates that the treatment is not appropriate.
Standards and treatment guidelines
• Physiotherapists work according to a number of national and international standards and/or guidelines and in addition have to work within mandatory and statutory policies.
• The specialist area of community paediatrics requires physiotherapists to be aware of the additional legislation involved in working with children in the community.
• A physiotherapist working with children must be familiar with all of the regulations and guidance listed in Table 5.1.
• The reader is referred to the assessment volume for community paediatrics for additional working practices particular to working as a physiotherapist with children.
Table 5.1 Regulations relevant to physiotherapists working with children
| Common assessment framework (CWDC 2009) | Identifies problems early and offers holistic co-ordinated approach to supporting families Non statutory guidance |
| National Skills Framework for Child Health and Maternity (DOH 2004) | Programme to improve children’s health. Sets standards for Social Services and Health. For latest amendments refer to: DOH: NSF for child health and maternity |
| Convention on the Rights of the Child 1990 (UN 1990) | International laws protecting a child’s civil, cultural, economic, political and social rights Formal agreement between states belonging to the United Nations |
| Education Act 1996 (UK Gov 1996) | Duties for educating children with special educational needs in mainstream or special schools Statutory regulation |
| Early Support 2010 (DCSF 2010a) | Supports parents and carers of disabled children aged five and under Covered by the Childrens’ Act 2004 |
| Transforming Community Services 2009 (DOH 2009) | Setting the agenda for commissioners and providers of community healthcare Guidance document |
| Working together to Safeguard children (DCSF 2010b) | The responsibility of all adults working with children Statutory guidance |
Treatment environment
• Treating children in a hospital setting is relatively straightforward, with purpose-designed treatment rooms, plenty of space, relatively few distractions with equipment on hand to make the task easier to carry out.
• Treating in a hospital environment has many advantages; however, it is difficult to replicate the home in a hospital department.
• If treatment is organised to take place where the child lives, the interventions can be designed to fit realistically into the child’s daily life.
• This can be repeated at school or other settings the child attends, so that a broader team is brought into the treatment process.
• The broader team will involve anyone who spends sufficient time with the child, such that they need to be trained in how to contribute to their physiotherapy programme.
• Treatment in school educational settings is obviously vital, but at the different stages in a child’s life the emphasis of the interventions will change as the child matures and develops.
• Suitable rooms and privacy can become an issue as the child gets older, for example, while treatment within the classroom might be ideal in primary school, it is not appropriate when the child is attending mainstream secondary education.
• The transition between primary and secondary is often a time where the emphasis of therapy changes, as the pressures of time within a school day intensify.
• Physiotherapy within school may be about hands-on therapy, but it is also important to provide advice for PE staff or for staff to become familiar with the requirements of the child mobilising generally around the school environment.
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