Paediatric MDT Service Beacon Hospital 1
Who Are We? 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 2
Global Developmental Delay MDT assessment Beacon Hospital 3
Case Study - TOM 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: 3 rd 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 • 4
Physiotherapy assessment Developmental Milestones achieved Relevant medical and birth history Tone Reflexes Gross motor abilities in all developmental positions Transitions Standarised assessment of motor skills 5
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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 7
Physiotherapy assessment and treatment 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 • of referral sent Letter back to GP outlining assessment and treatment plan • Discharged to community services at 24 months • 8
Speech and Language Therapy 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 9
Speech and Language Assessment Play FEDS Social Communication screen Clinical History/ observation/ direct Ax Speech Receptive language Screen Expressive language 10
Speech and Language Therapy red flags Months Developmental Red Flag Tom (18/12) 6 months Does not laugh and squeal -ve Does not look towards new sounds 9 Has limited or no babble -ve Does not indicate when happy or upset 12 Does not point to objects +ve Does not use gestures such as waving or shaking head 15 Has not used first word +ve Does not respond to “no” and “bye - bye” 18 Does not use at least 6-10 words consistently +ve Does not hear well or discriminate between sounds 20 Does not use at least 6 consonant sounds N/A Does not follow simple commands 24 Has a vocabulary of less then 50 words N/A Has decreased interest in social interactions 36 Strangers have difficulty understanding them N/A Does not use simple sentences 11
Feeding Eating Drinking & Swallowing Ax Parents concerned about persistent drooling and difficulty weaning. Oro-motor/ sensory Ax Feeding Swallow History / Food Ax Diary Meal time Environment 12
Overview of his profile 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 13
Overall SLT Impression 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 14
Psychology Clinical Case formulation overview: Supports Information sources 1. Previous reports (MDT link) • Biological • Cognitive 2. Intellectual ability Ax General functioning support • Affective 2. Review adaptive behaviour plan for home • Behavioural 3. Health (disorder or disease) • Environmental 4. Participation (social) management 5. Context (environmental) 15
Tom’s referral query: 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 of ability or disability. Plan re Tom’s referral: Initial parent consultation and clinical observation. • Followed by clinical case formulation... • 16
Tom’s case specifics: • 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 observation and the Bayley Scales indicate Tom’s level of currently functioning is significantly in arrears of his same age peers. 17
Areas of need / difficulties; Areas of strength; • Communication : experiences difficulty listening for 1 Strengths : minute duration including topics of interest, delayed Tom is reported to present as a placid baby during the reaction when people are speaking to him (i.e., face day. His parents reported his toileting is regular and movement/expression), does not shake or nod head for consistent. Although Tom has not indicated any signs ‘yes’ or ‘no’., reduced eye contact although evident on of readiness to toilet train his parents report he will occasion. • change and feed with ease. Functional Pre-Academics ; limited building skills, difficulty co-ordinating point to specific body part. Tom has made several attempts to feed himself, with • Home Living: limited acknowledgement of a spill or his hands. He presents as clumsy, often missing his breakage, unaware of safety needs (i.e., will climb from mouth however his parents reported this has recently high chair) turned into a social game involving turn taking. • Leisure: difficulty attending to one toy for 1 minute duration, lack of reciprocation during social activities (i.e., Parental report highlighted a positive relationship pee-a- boo), parental report highlighted ‘zoned out’ presentation. between Tom and his two siblings, namely a clear • Self-Care; poor sleep hygiene routine, wakes regularly and expression of enjoyment and reaction during returns to parent bed. individual game activities with family members. • 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 18
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