Paediatric MDT Service Beacon Hospital 1 Who Are We? Experienced - - PowerPoint PPT Presentation

Paediatric MDT Service

Beacon Hospital

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• Experienced Paediatric HSCP’s
• Complete MDT:
• Speech and Language therapists
• Physiotherapist
• Child and Adolescent Psychologist
• Occupational Therapist
• Dietitian
• New and evolving services with scope for

MDT assessment, liaison and therapy input.

• No waiting list for review
• All therapists available via GP, Consultant,

MDT or self referral

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Who Are We?

Global Developmental Delay MDT assessment

Beacon Hospital

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17 month old boy referred from GP with concerns regarding development noted when attending for management of respiratory infection. PMHx: Full term Normal Delivery SH: 3rd child to parents. Mother at home as fulltime carer. Previous intervention: attended primary care community physiotherapy – referred by public health nurse. Received block of therapy and home programme. Parental Concerns:

• Not sitting
• Floppy
• Slow to progress compared to peers

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Case Study - TOM

Developmental Milestones achieved Relevant medical and birth history Tone Reflexes Gross motor abilities in all developmental positions Transitions Standarised assessment of motor skills

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Physiotherapy assessment

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Physiotherapy red flags

Months Developmental Red Flag Tom (17 months) All High / low muscle tone

• ve

All Asymmetry

• ve

All Regression of motor skills

• ve

4 Head lag in pull to sit

• ve

6 Not sitting with support, not rolling +ve Sitting with support but not rolling 7 Not sitting independently +ve 9 Not getting into a seated position +ve 15 Not walking +ve 18 Using Gowers manoeuvre to rise to stand N/A 20 Not running N/A

AIMS: 31/58 - indicative of a 6 month motor delay

• Significant gross motor delay.
• Concern re global development as no babbling, poor eye fixing

and following, poor motivation for toys

• Advised paediatrician review and referral to Speech and

Language therapy for assessment

• Differential Diagnosis:
• Primary motor delay V’s Global developmental delay
• No red flags re tone, regression – will continue to monitor
• Treatment: monthly reviews offered promoting gross motor

progression, transitions, handling skills, home programme and advice

• Slow steady progress achieved and objectively documented
• Discussion with parents regarding community services and letter
• f referral sent
• Letter back to GP outlining assessment and treatment plan
• Discharged to community services at 24 months

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Physiotherapy assessment and treatment

• 18 months when seen by SLT
• Referred by PT with motor delay and speech delay
• Carried out Communication Assessment through clinical history, play

based assessment and informal observation

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Speech and Language Therapy

Clinical History/

• bservation/

direct Ax

Play

Social Communication

Receptive language

Expressive language

Speech Screen

FEDS screen

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Speech and Language Assessment

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Speech and Language Therapy red flags

Months Developmental Red Flag Tom (18/12) 6 months Does not laugh and squeal Does not look towards new sounds

• ve

9 Has limited or no babble Does not indicate when happy or upset

• ve

12 Does not point to objects Does not use gestures such as waving or shaking head +ve 15 Has not used first word Does not respond to “no” and “bye-bye” +ve 18 Does not use at least 6-10 words consistently Does not hear well or discriminate between sounds +ve 20 Does not use at least 6 consonant sounds Does not follow simple commands N/A 24 Has a vocabulary of less then 50 words Has decreased interest in social interactions N/A 36 Strangers have difficulty understanding them Does not use simple sentences N/A

Parents concerned about persistent drooling and difficulty weaning.

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Feeding Eating Drinking & Swallowing Ax

Oro-motor/ sensory Ax Swallow Ax Meal time Environment Feeding History / Food Diary

language No words, delayed babble (early vocalisations) Play Little interest in toys- find an interest he likes Mouthing Casting No functional play No symbolic play Social communication Poor engagement/ interaction reduced gesture/ imitation, “zoned out” language Poor understanding of simple commands No words, delayed babble (early vocalisations) FEDS Drooling Difficulties weaning

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Overview of his profile

Tom presented as an 18 month old boy with delayed language, play and unusual social communication difficulties. This is within the context of a wider developmental delay that merits further assessment. Management Plan

• 1. Onward referral to Clinical Psychology and Paediatrician
• 2. Education and advice to parents to ensure they are upskilled to develop

language at home, address the drooling difficulties and progress the weaning process.

• 3. 2/12 review
• 4. MDT discussion

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Overall SLT Impression

Information sources

• 1. Previous reports (MDT link)
• 2. Intellectual ability Ax
• 2. Review adaptive behaviour
• 3. Health (disorder or disease)
• 4. Participation (social)
• 5. Context (environmental)

Supports

• Biological
• Cognitive
• Affective
• Behavioural
• Environmental

management

General functioning support plan for home

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Psychology Clinical Case formulation overview:

Referral Query: Query of Global Developmental Delay (GDD) indicates that an individual, under 5 years of age, has failed to meet expected developmental milestones in several areas of functioning. GDD applies to individuals who are unable to undergo systematic assessment of intellectual functioning, including children who are too young to participate in standardized assessments (DSM V; 315.8).

Of note: This diagnosis requires reassessment after a period of time to identify the level

• f ability or disability.

Plan re Tom’s referral:

• Initial parent consultation and clinical observation.
• Followed by clinical case formulation...

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Tom’s referral query:

• 17month old, initial referral query highlighted possible Global

Developmental Delay (GDD).

• Initial assessment including parent based clinical interview,

clinical observation, adaptive behaviour assessment scale (ABAS) and completion of the cognitive scale in the Bayley scales of Infant and Toddler development.

• Tom’s ABAS highlighted deficits in the areas of; conceptual,

social, practical and motor functioning. Results from clinical

• bservation and the Bayley Scales indicate Tom’s level of

currently functioning is significantly in arrears of his same age peers.

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Tom’s case specifics:

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Areas of need / difficulties; Areas of strength;

• Communication: experiences difficulty listening for 1

minute duration including topics of interest, delayed reaction when people are speaking to him (i.e., face movement/expression), does not shake or nod head for ‘yes’ or ‘no’., reduced eye contact although evident on

• ccasion.
• Functional Pre-Academics; limited building skills, difficulty

co-ordinating point to specific body part.

• Home Living: limited acknowledgement of a spill or

breakage, unaware of safety needs (i.e., will climb from high chair)

• Leisure: difficulty attending to one toy for 1 minute

duration, lack of reciprocation during social activities (i.e., pee-a-boo), parental report highlighted ‘zoned out’ presentation.

• Self-Care; poor sleep hygiene routine, wakes regularly and

returns to parent bed.

• Self-Direction: difficulty self entertaining, seeks adult

guidance and support for play, mouthing objects

• Social: Does not lift arms to request pick up, responds to

familiar or unfamiliar people in a similar manner

Strengths: Tom is reported to present as a placid baby during the

• day. His parents reported his toileting is regular and
• consistent. Although Tom has not indicated any signs
• f readiness to toilet train his parents report he will

change and feed with ease. Tom has made several attempts to feed himself, with his hands. He presents as clumsy, often missing his mouth however his parents reported this has recently turned into a social game involving turn taking. Parental report highlighted a positive relationship between Tom and his two siblings, namely a clear expression of enjoyment and reaction during individual game activities with family members.

• Support required to provide resource and strategies that aim to promote the development,

education, interest and personal well being of Tom and strategies that aim to enhance his individual functioning given the aforementioned difficulties. 1. Complete, score and write up standardised measures identifying Global Development Delay. Given the Adaptive functioning and cognitive ability measures within the ‘Extremely Low’ range the Psychological report will outline a diagnosis of GDD and provide information for the

• family. Include information re community services.

2. Link with other professionals involved, including referrer, Paediatric specialists (SLT, OT, PT), GP and Consultant Paediatrician. Onward referral to SLT for communication support, Occupational Therapy for functional skills and Physiotherapy for motor support. 3. Given the areas of difficulty mentioned provide individual psycho-education with Tom’s parents regarding concerns. Develop a positive behaviour support plan to enhance specific, targeted deficits. Follow up review in 3 months with parents given clear outline of goals. 4. Encourage peer based supports (i.e., play groups) and evidence based intervention including Floor time, structured social play games and visual systems to support communication, functional independence and anxiety/ behaviour difficulties. Backward chaining and scaffolding to enhance learning opportunities for Tom. During feedback of Psychological report examples and in depth discussion regarding the practical application of these recommendations will be discussed.

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Plan for Tom :

✓Medical work up completed out ruling underlying medical concerns ✓Confirmed diagnosis of global developmental delay ✓Provided therapeutic input ✓Identified and referred to appropriate community service - Early Intervention MDT ✓Continued to provide therapy input until uptake by community services or based on parental request. ✓Liaise within the MDT regarding onward referral and possible joint intervention opportunities.

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MDT discussion

Motor Communication Feeding Cognitive Strength slow steady progress Parental support Swallow WNL Progress with weaning, self feeding & drooling Social; responding well to floor time intervention. Weakness Impact of motivation Poor shared attention Ongoing restricted diet Significantly in arrears of same age peers regarding ADL.