Clinical Practice (assessment, diagnosis, treatment, knowledge translation/EBP, implementation science, program development)
Todd Levy, MS, OTR/L, CBIST
Clinical Specialist, Occupational Therapy
Children's Hospital of Philadelphia
The CDC estimates that 5 million Americans are living with disability from brain injury. Many acquire their injury in-utero or during childhood. Pediatric stroke is a major cause of death and disability and lasting functional sequelae in 60-70% of survivors (Ferriero 2019). While motor impairments are common in children with stroke (deVeber 2000), long-term neurobehavioral and neurocognitive deficits are also common and can significantly impact goal attainment (Greenham 2018, Greenham 2016). Our team will share expertise in pediatric stroke to guide clinicians to identify and address impairments presenting barriers to activity- and participation-level goals for school-aged children 5-19 years of age in the chronic stage of disability following brain injury.
Many therapists do not feel well prepared to address neurocognitive and neurobehavioral deficits, and lack access to experts in cognition and behavior. A recent review of non-pharmacological interventions for pediatric stroke found only three studies examining interventions to address cognition (Mirkowski 2019). Given the access clients have to OT and PT services, and the shift to activity- and participation-level goals and interventions, our team will discuss ways to leverage up-to-date evidence of techniques within the traditional scopes of OT and PT, and collaborative models. In addition, we will suggest considerations for expanding the traditional repertoire of OTs and PTs to evidenced-based cognitive rehabilitation interventions to better meet the needs of the family.
According to the International Classification of Functioning, Disability, and Health (ICF), rehabilitation professionals should be concerned with activity- and participation-level of functioning. Performance at these levels is often a product of multiple person and environmental factors (WHO 2007). For example, anxiety might be a barrier to a child achieving the goal of playing baseball. In this case, the rehabilitation team must address anxiety. This session will discuss leveraging neuropsychology reports and interdisciplinary and consultative approaches when psychology and psychiatry services are available. We will outline strategies to help OTs and PTs when cognitive and behavioral specialists are unavailable. Evidence from coaching models of therapy suggest Occupational Therapists can enhance participation by modifying the environment and coaching adolescents and parents to succeed in the face of myriad impairment-level barriers (Anaby 2018). Coaching families to set challenging but realistic participation-oriented goals using small progressive steps provide momentum (Schwellnus 2020) and can the stage for shifting children out of the clinic and into real life situations. Clients that have specific plans to achieve goals within personal contexts are statistically more likely to achieve their goals (Gollwitzer 1997). It is often during participation in real social contexts that children are challenged to self-problem solve and identify new goals.
A recent prospective, longitudinal study involving 656 children with cerebral palsy found that children were more likely to achieve greater participation in structured play and recreational activities when therapy focused on participation in family-centered activities. Performance in self-care was also more likely to improve when therapy focused on overall health and well-being. How occupational, physical, and speech therapy services were provided was found to be more important than the amount of therapy (Westcott Mccoy 2019). Working with children and their caregivers to achieve activity- and participation-level goals requires a holistic approach beyond the skill set of the individual allied rehabilitation clinician. The session will include specific strategies to solve this complex, pressing problem and encourage the audience to share ideas and insights.
Specifically, the presenters will discuss the use of basic clinical skills such as “therapeutic use of self" (Knight 2012), selecting “just right challenges" (Csikszentmihalyi 1990, Guadagnoli 2004, Sullivan 2008), and the art of engaging caregivers in conversations about how best to support and optimize mental health for their child, including seeking out services when needed. The speakers will review the critically important framework of integrating capacity, skill, and motivation into intervention plans to help patients attain goals that are meaningful to them (Winstein 2014). We will examine how to incorporate basic cognitive strategies such as rehearsal, task simplification, and “attention to doing” (Toglia 2012) into activity-level treatment interventions. We will consider how The Cognitive Orientation to Daily Occupational Performance (CO-OP) can help children learn to perform new skills involving myriad cognitive and motor components (Dawson 2917). We will review motor learning principles including modeling performance, providing effective feedback, facilitating implicit and explicit processing, errorless learning strategies and generalizing skills (Gentile 1998; Gordon & Magill 2012; Kleim 2012; Mount 2007; Muratori 2013; Zwicker 2009).
The use of evidenced-based cognitive rehabilitation interventions within the context of common Occupational and Physical Therapy goals will be reviewed (Laatsch, et. al, 2019). For example, it is now considered a Practice Standard (highest level of evidence) to incorporate Attention Process Training (ATP) for children with moderate to severe TBI, or the Amsterdam Memory & Attention Training for Children (AMAT-C) for those with TBI and other types of acquired brain injuries. An Executive Functioning Online Based Problem-Solving Intervention will be presented that is now a Practice Standard. Metacognitive training strategies will also be presented, although the evidence for their effectiveness in children is more limited (Practice Guideline).
This session will include an opportunity for the audience to share their insight and strategies for addressing neurocognitive and neurobehavioral barriers to activity- and participation- level rehabilitation goals and identify gaps in the research that should be addressed in future work. We welcome insights and ideas for enhancing interdisciplinary models to address these goals, as well as treating such goals holistically in communities with less access to cognitive and behavioral specialists.