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Intervention and DCD- considerations for practice

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This presentation covers the key concepts that need to be considered when managing the individual with DCD , using a bio-psychosocial model of practice.

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Intervention and DCD- considerations for practice

  1. 1. Intervention <ul><li>Why intervene </li></ul><ul><li>When intervene </li></ul><ul><li>How long </li></ul><ul><li>What to do </li></ul><ul><li>Teach a task or teach a skill </li></ul>
  2. 2. What to consider in intervention Bronfrenbrenner
  3. 3. ICF model
  4. 4. Who is disabled? <ul><li>What is disabled? </li></ul><ul><li>Dyspraxic or a child with dyspraxia </li></ul><ul><li>Disability Student Allowance.. Who is disabled? </li></ul>
  5. 5. Approaches used in DCD <ul><li>Top down </li></ul><ul><li>Task specific </li></ul><ul><li>Cognitive Orientation to Occupational Performance (CO-OP) </li></ul><ul><li>Verbal self-guidance </li></ul><ul><li>Neuromotor task training </li></ul><ul><li>Cognitive-motor </li></ul><ul><li>Ecological </li></ul><ul><li>Bottom up </li></ul><ul><li>Sensory integration </li></ul><ul><li>Kinaesthetic training </li></ul><ul><li>Perceptual motor </li></ul>
  6. 6. Intervention <ul><li>Traditional approaches to intervention have aimed at remediating the motor deficit using “bottom up” approaches </li></ul><ul><li>Sensory integration </li></ul><ul><li>Perceptual-motor </li></ul><ul><li>Kinaesthetic training </li></ul>
  7. 7. Sensory integration (SI) <ul><li>Empirical evidence does not support SI as an effective intervention </li></ul><ul><li>At best SI is as effective as any other intervention in improving motor skills </li></ul><ul><li>SI is most costly intervention </li></ul><ul><li>Lacks a functional approach </li></ul><ul><li>Mandich, Polatajko, Macnab, Miller 2001 </li></ul>
  8. 8. Sensory integration (SI) <ul><li>Theoretical basis of sensory integration therapy is not supported by our current knowledge of motor development, learning and control. Wilson PH 2006, Sugden & Dunford 2006 </li></ul><ul><li>Move to task orientated approach is supported by the literature. Polatajko & Cantin 2006 </li></ul>
  9. 9. If SI is chosen as an approach <ul><li>Should always be approached as a trial with clear, measurable, functional outcomes </li></ul><ul><li>Education of families, teachers & others should accompany intervention </li></ul><ul><li>Attention should be given to adapting environment as well </li></ul><ul><li>Re-assessment using outcomes after 8-10 weeks intervention – if no benefits another approach should be considered </li></ul><ul><li>CanChild website, Keeping Current/SI </li></ul>
  10. 10. Process-orientated/kinaesthesia <ul><li>Some results show it to be equally as effective as other approaches </li></ul><ul><li>Some results indicate it is no better than no treatment </li></ul><ul><li>Evidence in support of the process orientated approach is inconclusive Mandich, Polatajko, Macnab, Miller 2001 </li></ul>
  11. 11. Perceptual-motor <ul><li>Meta-analysis of 180 studies: results showed perceptual motor intervention was not effective in remediating the motor difficulties of children with (specific) learning disabilities </li></ul><ul><li>Mandich, Polatajko, Macnab, Miller 2001 </li></ul>
  12. 12. Conclusions from intervention literature <ul><li>Bottom up approaches – no support for one approach over another, no evidence of impact on functional everyday tasks </li></ul><ul><li>Top down approaches </li></ul><ul><ul><li>Task specific - effective in teaching task but not sure about transfer & generalisation </li></ul></ul><ul><ul><li>Cognitive – improves performance of activity, some evidence of transfer & generalisation ? Evidence of increased participation </li></ul></ul><ul><li>Polatajko & Cantin 2005 </li></ul>
  13. 13. Intervention: Leeds Consensus <ul><li>Should contain activities that are functional and are based on those that are relevant to daily living and meaningful to the child, parents, teachers and others. These should be based on accurate assessment and aim to improve the child’s motor functions plus other attributes such as self esteem and confidence. </li></ul>
  14. 14. Intervention: Leeds Consensus <ul><li>Involve the child’s wishes as key parts of the intervention process. This will usually include identifying functional tasks, choosing priorities, establishing targets for success and engaging in monitoring their own progress. </li></ul>
  15. 15. Intervention: Leeds Consensus <ul><li>Involve a number of individuals who can contribute - parents, teachers, health professionals, coaches and other family members – to enhance generalization and application in the context of everyday life. </li></ul><ul><li>Accommodate the contextual life of the family taking into account family circumstances such as routines, siblings, finance, etc. </li></ul>
  16. 16. Intervention: Leeds Consensus <ul><li>Be evidence-based and grounded in theories that are applicable to understanding children with DCD. These theories should take into account the nature of the learning process in the developing child, the structure of the task and the environmental conditions that support skill acquisition. </li></ul>
  17. 17. Top down functional approaches <ul><li>Task specific </li></ul><ul><li>Cognitive-motor </li></ul><ul><li>Ecological intervention </li></ul><ul><li>Cognitive orientation to occupational performance (CO-OP) </li></ul>
  18. 18. Task specific <ul><li>Child works on specific task while also learning underlying movement principles (implicit learning) that may transfer to other related tasks </li></ul><ul><li>Acknowledges the unique set of movement skills required for a particular task </li></ul><ul><li>The child is given the opportunity to practice the task </li></ul><ul><li>Clinician uses skills of task analysis, modification and adaptation to enable the child to achieve the task </li></ul><ul><li>Beneficial to children with DCD if conducted 3 to 5 times a week in a group or home setting. Pless & Carlsson 2000 </li></ul>
  19. 19. Cognitive motor approach <ul><li>Emphasis on child performing functional tasks in everyday life settings </li></ul><ul><li>Movement competence is a problem solving exercise involving action planning, execution & evaluation </li></ul><ul><li>Interaction of cognitive, affective & motor competencies </li></ul><ul><li>Derived from motor learning & motor development literature </li></ul>
  20. 20. Motor Development and Learning <ul><li>Resources of the Child </li></ul><ul><li>Outcomes </li></ul><ul><li>Environment in which Manner of </li></ul><ul><li>Activity occurs presentation </li></ul>
  21. 21. Ecological intervention <ul><li>Tasks taught in groups representing classes of activities to facilitate generalisation </li></ul><ul><li>Consider the child’s wishes & priorities </li></ul><ul><li>Involve a number of individuals – parents, teachers, health professionals </li></ul><ul><li>Evidence based & grounded in theories applicable to DCD </li></ul>
  22. 22. CO-OP <ul><li>Client centred approach focused on strategy based skill acquisition 4 objectives </li></ul><ul><li>skill acquisition (primary aim) </li></ul><ul><li>cognitive strategy use </li></ul><ul><li>generalisation </li></ul><ul><li>transfer </li></ul><ul><li>Early evidence suggests this is an effective approach to improving functional performance in children with DCD </li></ul>
  23. 23. Family centred functional therapy <ul><li>Family-centred functional therapy (FCFT) has been developed by the McMaster team in Canada. </li></ul><ul><li>FCFT is based on concepts from family centred services and uses a systems approach to motor development. </li></ul><ul><li>Addresses not just the individual capacities of the child but considers the task and environment as potential vehicles for change. </li></ul><ul><li>It is still an emerging clinical model for children and so far has only been applied to children with cerebral palsy </li></ul>
  24. 24. 4 clinical principles <ul><li>Promoting functional performance </li></ul><ul><li>Identifying periods of change </li></ul><ul><li>Identifying and changing the primary constraints in the task, child and/or environment that prevent achievement of the task </li></ul><ul><li>Encouraging practice </li></ul>
  25. 25. Individual or group? <ul><li>Individual – tailored to specific needs of the child but ? Context. Also resource intense </li></ul><ul><li>Group harder to tailor to individual but peer group benefits & resource efficient. Opportunity for children to meet others like them, can run parent groups alongside </li></ul>
  26. 26. Results: Clinical judgement <ul><li>Coordination improved – MABC, camp </li></ul><ul><li>Writing improved - sitting position, hand on paper, mum says she can now understand writing in homework book. </li></ul><ul><li>Can now do own laces (occasionally come undone) </li></ul><ul><li>Ball skills - no change on MABC but improvement in football skills noted by parents, child and OT </li></ul><ul><li>Running & trying new things on the playground – he says no longer an issue </li></ul>
  27. 27. Conclusions <ul><li>Task specific approach effective beyond just teaching the task </li></ul><ul><li>Intensive scheduling effective plus satisfying way of working – get to know children well </li></ul><ul><li>Group has effect on child’s perceptions/beliefs </li></ul><ul><li>Outcomes are complex and hard to measure </li></ul><ul><li>COPM useful tool for measuring goal attainment </li></ul>
  28. 28. The evidence - Summary <ul><li>“ If a clear message has come from research over the past decade, it is that performance of an activity is best learned by practising the activity itself.” </li></ul><ul><li>Mary Law 2002 </li></ul>

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