Developmental Impairment/Learning Disability Pathway

Greater Glasgow and Clyde

Developmental Impairment/Learning Disability Pathway

Population and Pathways

What type of child/young person would it be appropriate to see within this pathway?

Any child/young person between the ages of 0 and 18 years who is understood to have an issue with learning which is impacting on their occupational performance could be seen within this pathway.  For younger children, this would often be described as global developmental delay or developmental impairment.  Children with genetic or chromosomal conditions which result in a delay in development or learning disability would also fit within this pathway.  Often these children/young people do not have a specific condition but any child/young person who does not learn/develop skills in a typical way could be seen in this pathway.  Their development is generally slow and protracted and they typically need extra support to gain skills.  For the most part it would not be appropriate to see children with a neuro-disability (where differences in muscle tone impact on function) to follow this pathway, see the Neuro-disability Pathway.

 

How would these children/young people and their families access the Occupational Therapy Service?

These children and young people would mainly come to the service through the Disability Pathway or through uni-professional referral from parents/carers, education, and other professionals.  On occasions they may come through the Vulnerability Pathway.

 

What would a typical referral look like?

In the early years referrals are generally made by other professionals and are looking for input to support play and self-feeding skills due to delayed sitting and reduced fine motor skills.  The referrer is often looking for support around seating to promote function. 

As children approach nursery age the areas that children need support in widens to include other independence/self-care skills as well as self-feeding and play skills.  In the ante-preschool and pre-school years attention often turns to readiness for school and planning for the transition to school. 

In primary aged children the focus is often on more specific skills required for school (handwriting, independence skills, motor skills to support participation in PE, attention and organisation) as well as around independence with self-care skills at home and in the community.  As they move through primary school the focus moves to readiness for transition to secondary school. 

During secondary school years the focus is generally around school activities (handwriting/recording work/exams, organisation, independence skills and accessing practical subjects) and independence within the home and community environment.

Currently we receive few requests to support families with the transition to adult services but this may be something we look at more in the future.

 

 

Evidence Base

The evidence for this population supports the following approaches:

  • Early intervention
  • Family centered care
    • Response – Contingent Child Learning (setting up the environment to elicit the learning behavior required can support development).
    • Parent Responsiveness to Child Behavior (parents’ sensitivity and responsiveness to their child’s behavior during parent-child interactions influences development).
    • Everyday Natural Learning Opportunities (a powerful context for child learning).
    • Capacity-Building Help-Giving Practices (by building capacity in families and giving help to families you can impact on child development).
  • The use of teaching-learning approaches in Occupational Therapy
    • Grading (finding the ‘just right’ challenge for the child).
    • Chaining (teaching one step at a time).
    • Adapting the environment/task (changing the environment or task to promote success).
    • Video prompting (video clips of steps of tasks that can be viewed immediately prior to practice and feedback given).
    • Practice with error correction (giving immediate, explicit feedback to prevent the practice of error).

Staged Journey of Care

National Drivers such as Ready to Act and “Guan Yersel!” The Self-Management Strategy for Long Term Conditions in Scotland advocate for the use of a tiered model of service delivery as well as supporting those with long term conditions to self-manage their conditions.  As such the focus for this population is on developing self-management skills as these types of conditions are life-long and it is essential to empower parents/carers with the skills they need to support their child into adulthood.   We want families to be able to access services at a targeted level and then if required to access specialist services for specific support before returning to a universal or targeted level.

Specialist Children’s Services Occupational Therapy GG&C Developmental Impairment/Learning Disability Pathway

Universal and Targeted Level

The messages we want to ensure reach all families and professionals working with children with a developmental impairment or learning disability are:

  • It is important to involve children in play and self-care as early as possible.
  • Participation and practice in play/leisure, self-care and education are essential for wellbeing and can support skill development.
  • Appropriate positioning for play/leisure, education and self-care skills can support development.

Resources available at a Universal level that can be accessed by families of children with a developmental impairment or learning disability include:

Ready Steady Baby and Ready Steady Toddler are booklets supplied by Midwives and Health Visitors.

 

Ready Steady Baby will help you get ready for parenthood by taking you through the whole of your pregnancy - from the decision to start trying for a baby, through the antenatal care you will receive and on to advice on labour and birth. It offers advice on maternity leave and benefits and tips on caring for your baby for the first year.  The comprehensive guide is for mums, dads, partners, civil partners and other primary care givers who all have a very important role to play in the care and upbringing of your baby.

  

Ready Steady Toddler explores a hands-on guide to help you through the challenges and rewards of the toddler years.

 

 

 

 

 

 

[email protected] (Baby, Toddler and Pre-school) books are supplied by Health Visitors.

Play, Talk, Read is a website with easy, fun ways to help your child be happier, learn more and enjoy a better start in life. 

 

 

Read Write Count is a website where parents and carers can find ways to help their children learn vital life skills like reading, writing and counting.

 

 

Bookbug support families so that from birth, stories and songs are used to build attachment, support speech and language development and lay the foundations of literacy. This is the first step in helping every child in Scotland to develop a love of books and reading.

Play Scotland works to promote the importance of play for all children and young people, and campaigns to create increased play opportunities in the community.

 

Parentzone Scotland - Education Scotland is the national body in Scotland for supporting quality and improvement in learning and teaching.

 

Parenting Across Scotland is a partnership of charities which offers support to children and families in Scotland.  They work together to focus on parenting issues and to help realise their vision..."A Scotland where all parents and families are valued and supported to give children the best possible start in life.

 

Resources available at a Targeted level that can be accessed by families of and professionals working with children with a developmental impairment or learning disability include:

  • KIDS Scotland Platform
  • Workshops for families (available now by contacting Advanced Practitioner for this pathway).  The workshop can be presented on an individual basis or in small groups as required by the individual or taking account of services needs.
  • Workshops for education establishments (coming soon).

Other useful links include

  • Paving the Way - Website offering early intervention for children with learning disabilities whose behaviours challenge.
  • Down Syndrome Scotland - A parent led charity providing 'all through life' support nationally across Scotland for those with Down Syndrome, their families and those working with them.
  • The Scottish Commission for Learning Disability (SCLD) - SCLD aims to be knowledge hub - offering support, information and new ideas about learning disability in Scotland.
  • Change People - Is an organisation led by people with (learning) disabilities who work together for equal human rights.  They have parenting resources for parents with a learning disability.

Specialist Level

Specialist input may be required to support families/teams around the child in the early stages to identify realistic goals, access relevant information and develop strategies specific to their child with the aim of empowering the family/team around the child to transition to a targeted level. Families/teams around the child may also receive specialist input if they have tried available targeted input and the child/young person is not making progress towards their goals within a 6 month period. Specialist input may also be required if adaptive equipment is required to enhance participation.

Specialist level intervention will be accessed on an individual basis with a focus on functional outcomes. Carers of those requiring specialist level intervention can also access the workshop. Individual therapist can request support with clinical decision making and implementation of evidence based practice for this population by contacting the Advanced Practitioner for this pathway.

Specialist level intervention should include the following stages:

  • Identification of the child/young person’s priorities and/or those of the team around the child/young person as appropriate - using participation/occupation focused assessment tools and reviewing progress towards goals using outcome measures if the child is returning to the clinic.
  • Assessment of current barriers to occupational performance - this will include detailed observation of the child/young person completing the occupations in question and if required assessment of the child/young person’s component skills.
  • Goals set collaboratively with child/young person and/or team around the child.
  • Treatment plan (including plan for review to evaluate effectiveness) discussed with child/young person and/or the team around the child as appropriate. The typical length of an episode is 3 months. This allows time for learning and consolidation prior to review.
  • Treatment which may include:
  1. Intervention with OT or OT Technical Instructor (TI) to work on specific goals.
  2. Child/Young Person specific advice and strategies to home and/or nursery/school to support the attainment of specific goals.
  3. Liaison with the team around the child/young person.
  4. Equipment review (home and/or education).
  • Review following treatment to ensure progress towards goals and evaluate effectiveness.
  • Discharge from service with sign posting to universal and targeted resources, and when to seek further help in the future.

Tool Box

Assessment Tools:

Participation Focused

  • Participation and Environment Measure.
  • Paediatric Evaluation of Disability Intervention.


Occupation Focused

  • Canadian Occupational Performance Measure (COPM).
  • Perceived Efficacy and Goal Setting Tool (PEGS).
  • Child Occupation Self-Assessment (COSA).

Outcome Measure:

Robust goal setting - Goal Attainment Scale (GAS), COPM, PEGS and non-standardised.

Interventions:

  • Activity Analysis - Analysis of an activity to identify the particular demands of that activity, the range of skills involved and the social and cultural meaning that can be attributed to it.
  • Dynamic Performance Analysis - Analysis of actual performance of an occupation acknowledging the link between the person, environment and occupation.
  • Grading/Adapting the Task - Changing the task or breaking it down into steps to make it easier or harder depending on the goal.
  • Chaining - Teaching one step at a time. Forward chaining = teaching each step in turn starting with the first step. Backward chaining = teaching each step in turn starting with the last step.
  • Adapting the Environment - Changing the environment to promote success.
  • Fading - Reducing the amount of help given in stages.
  • Video Prompting - Video prompting is an instructional tool, which involves showing video clips of short segments/steps of a skill sequentially. Immediately after watching the video clip of a step the student then has the opportunity to practice the step and receive feedback.

Advantages of video prompting:

  1. Consistency of instruction across several different instructors.
  2. Repeated practice opportunities (the video remains static and can be used repeatedly over time without their being any subtle changes).
  3. Reinforcing quality of video and device used to show video (e.g. laptop, iPad etc.).
  4. Provides opportunity for immediate feedback.
  • Practice with Error Correction - Error correction provides participants with immediate, explicit feedback to prevent them from practicing errors in the future. The level of prompting given when an error is made can be adjusted and tends to be used from least intrusive to most intrusive. 

Below is the flow chart of the systematic error correction procedure used in the video prompting intervention from Gardner & Wolfe (2015).

  • Other Pathways - Other pathways may also offer intervention options which the child/young person and their family can access depending on the child/young person’s individual strengths and needs e.g. CO-OP may be of benefit for children/young people with milder learning disabilities, sensory pathway may be helpful in some cases.

Resources (being developed):

  • Early Play Skills Activity Kit.
  • Self-care Activity Kit.
  • Workshop Slides and Resources.

Skills Mix - Role of each Banding

Further Reading

Evidence for early intervention and family centred care:

  • Dunst, C.J. (2007). Chapter 8 – Early Intervention for Infants and Toddlers with Developmental Disabilities. In Odom, S.L., Horner, R.H., Snell, M.E. and Blacher, J. (Eds). Handbook of Developmental Disabilities. New York: The Guilford Press.
  • Dunst, C.J., Trivette, C.M. and Deal, A. (1988). Enabling and Empowering Families. Cambridge, MA: Brookline Books.

Response-Contingent Child Learning – environmental arrangements by which child’s behaviour produces or elicits a reinforcing consequence:

  • Dunst, C.J. (2003) Social-emotional consequences of response-contingent learning opportunities. Bridges, 1(1), 1-17.
  • Hutto, M.D. (2003) Latency to learn in contingency studies of young children with disabilities or developmental delays. Bridges, 1(2), 1-16.
  • Dunst, C.J., Storck, A.J., Hutto, M.D. and Snyder, D. (2006) Relative effectiveness of episodic and conjugate reinforcement on child development. Bridges, 4(3), 1-15.

Parent Responsiveness to Child Behaviour – Parents’ sensitivity and responsiveness to their child’s behaviour during parent-child interactions influences development:

  • Trivette, C.M. (2003) Influence of caregiver responsiveness on the development of young children with or at risk for developmental disabilities. Bridges, 1(3), 1-13.
  • Trivette, C.M. (2004) Influence of home environment on the social-emotional development of young children. Bridges, 2(7), 1-15.
  • Trivette, C.M. and O’Herin, C.E. (2006) Characteristics of caregiver responsiveness and child competence, Bridges, 4.

Everyday Natural Learning Opportunities – powerful context for child learning:

  • Raab, M. and Dunst, C.J. (2006) Influence of child interests on variations in child behaviour and functioning. Bridges, 4(2), 1-22.
  • Trivette, C.M., Dunst, C.J. and Hamby, D. (2004) Sources of variation in and consequences of everyday activity on child and parent functioning. Perspectives in Education, 22(2), 17-35.

Capacity-Building Help-Giving Practices

  • Trivette, C.M., Dunst, C.J. and Hamby, D. (2004) Sources of variation in and consequences of everyday activity on child and parent functioning. Perspectives in Education, 22(2), 17-35.
  • Dunst, C.J. and Dempsey, I. (2007) Family/Professional partnership and parenting competence, confidence and enjoyment. International Journal of Development, Disability and Education, 54(3), 305-318.

Evidence for using teaching-learning approaches in OT

  • Greber, C., Ziviani, J. and Rodger, S. (2007). The Four-Quadrant Model of Facilitated Learning (Part 1): Using teaching-learning approaches in occupational therapy. Australian Occupational Therapy Journal. 54, S31-S39.
  • Greber, C., Ziviani, J. and Rodger, S. (2007). The Four-Quadrant Model of Facilitated Learning (Part 2): strategies and applications. Australian Occupational Therapy Journal. 54, S40-S48.

Use of video prompting as an instructional tool

  • Graves, T.B., Collins, B.C., Schuster, J.W. and Kleinert, H. (2005) Using video prompting to teach cooking skills to secondary students with moderate disabilities. Education and Training in Developmental Disabilities, 40, 34-46.
  • Mechling, L (2005). The effect of instructor-created video programs to teach students with disabilities: A literature review. Journal of Special Education Technology, 20(2), 25-36.

Practice with error correction

  • Cannella-Malone, H.I., Fleming, C., Chung, Y.-C., Wheeler, G.M., Basbagill, A.R. and Singh, A.H. (2011). Teaching daily living skills to seven individuals with severe intellectual disabilities: A comparison of video prompting to video modelling. Journal of Positive Behaviour Interventions, 13, 144-153.
  • Gardner, S.J. and Wolfe, P.S. (2015) Teaching Students with Developmental Disabilities Daily Living Skills Using Point-of-View Modelling Plus Video Prompting with Error Correction. Focus on Autism and Other Developmental Disabilities, 30(4), 195-207.

 

 

Case Study

John is 10 years old and has a diagnosis of Down syndrome.

First Contact


Parental concern is that John does not participate in household chores like his siblings and mum doesn’t know if she should encourage this or not. In John’s family, doing chores is linked to pocket money. Mum is keen that John develops life skills for when he is older.

John participates in chores once or twice a month and is minimally involved. Both John and mum do want participation to change, they want John to be more involved in family chores and John is motivated to earn more pocket money.

John and parents identified what they wanted participation to look in the future:

  • Keeping his room tidy on a daily basis,
  • Clearing the dinner table 3 times a week and
  • Cleaning out the rabbit’s hutch once a week.

Information provided at a targeted level

Parents given strategies to develop these skills and offered further appointment to review progress if required.

  • Provided with visual homework charts to keep track of progress.
  • Parents given reassurance to encourage John to participate and learn new skills.
  • Provided 30 minutes of advice around grading the activity for success and breaking the task into achievable steps.

Evaluation

John and parents make another appointment in 5 weeks.
John has achieved clearing the table and the cleaning of the rabbit’s hutch. He has struggled to keep his room tidy.

Scenario A – more input at targeted level
Keep him in the targeted loop.
We talk through adapting the environment, ensure there is a place for everything and it is clear to John where everything goes. Provide support and information on where it was breaking down. Ask them to continue for another 6 weeks.

Scenario B – specialist input
Decided that the family would benefit from 3 - 4 sessions of specialist input to give a bespoke plan, involving a home visit to assess the environment, visual aids, checklists – all with the intention of skilling family up to cope with greater demands in the future.