Mental Health Care in Pediatric Rehabilitation Hospitals: A Biopsychosocial, Collaborative, and Agency-based Service Integration Approach

Background: Canadian hospitals are not currently prepared to meet the psychosocial needs of children with disabilities as services are rooted in a biomedical care model. Objective: To describe a practical and holistic framework for pediatric rehabilitation hospitals to meet the health care needs of children and their families. Method: An environmental scan was conducted of best practice guidelines, policy documents, and models of integrated mental health care. Recommendations from clinical guidelines and national strategy documents were incorporated to develop a service integration approach. Results: An agency-based approach was used to develop a two-phase biopsychosocial framework. In framework Phase I, reactive care is provided to mental health concerns. In Phase II, there is a shift to proactive care and mental health wellbeing. Conclusions: Emphasis is placed on capacity building of clinical staff into best practices for mental health care. Implementation needs and consideration for uptake of the framework are also discussed.

Solution-Focused Coaching in Pediatric Rehabilitation: Perceived Therapist Impact

Aims: This qualitative descriptive study explored perceived impacts of solution-focused coaching in pediatric rehabilitation (SFC-peds) from the viewpoint of experienced therapists.Methods: Semi-structured in-depth interviews were conducted with six participants (four occupational therapists and two physical therapists) who had incorporated SFC-peds into their practice for three years or longer. Participants were asked to describe perceived differences SFC-peds has made to their clinical practice, service provision, and relationships with clients and families. Interview transcripts were analyzed using the method of thematic analysis.Results: Three major themes, each with subthemes, were identified: 1) changes in therapists' perception of their roles; 2) increased service effectiveness; and 3) enhanced client capacity. Through long-term engagement with SFC-peds, participants have experienced a role shift from an expert adviser to a collaborative facilitator who assists clients and families with capacity building and self-discovery of solutions for their everyday environments.Conclusions: The findings suggest that SFC-peds can help participants reframe professional expertise and integrate principles of family-centred care into their day-to-day practice. Individual- and system-level support, along with flexibility in service structures and processes, may be needed to further the implementation of SFC-peds in service delivery.

A Solution-Focused Coaching Intervention with Children and Youth with Cerebral Palsy to Achieve Participation-Oriented Goals

Background: The ultimate goal of therapeutic intervention is meaningful participation in one's world. For people with Cerebral Palsy (CP), limitations can often become a focus of care.Aim: Our purpose was to investigate the impact of a Solution-Focused Coaching intervention designed for pediatric rehabilitation (SFC-peds) on the attainment of participation goals for children/youth with CP.Method: Twelve participants participated in a repeated measures quantitative study and in qualitative interviews. Children and youth (ages 6-19) and their families participated in three to five coaching sessions, including an initial baseline goal setting session, with one additional follow-up session as well as the qualitative interviews. The Canadian Occupational Performance Measure and Goal Attainment Scaling were incorporated into initial coaching sessions and then re-administered by a blind assessor within one month post-intervention. Qualitative interviews were conducted at this time.Results: Statistically significant improvements were found in goal performance, satisfaction, and attainment. Interview data included consideration of both the content of the intervention (what the practitioner is doing) and the unique SFC-peds process (how the client feels about the intervention).Conclusions: SFC-peds may present an effective approach for working with children/youth with CP to achieve self-selected participation-oriented goals in a relatively short time-period.

Children and Teens in Charge of their Health (CATCH): A protocol for a feasibility randomised controlled trial of solution-focused coaching to foster healthy lifestyles in childhood disability

INTRODUCTION

Children with physical disabilities are rarely included in interventions to promote healthy lifestyles, despite being at higher risk for suboptimal dietary and physical activity behaviours. The Children and Teens in Charge of their Health study explores the feasibility and acceptability of conducting a randomised controlled trial (RCT) of a strengths-based, solution-focused coaching intervention for improving and sustaining physical activity and healthy dietary habits in children and young people with physical disabilities.

METHODS AND ANALYSIS

Thirty children aged 10-18 years with a diagnosis of spina bifida or cerebral palsy who are able to set healthy lifestyle goals will be recruited from two children's rehabilitation hospitals in Ontario, Canada. Participants will be enrolled in the study for twelve months. All participants will receive standard care and printed information about healthy lifestyles. Of the 30 participants, 15 will be randomised to receive a coaching intervention for the first 6 months. Health indicators and psychosocial outcomes will be assessed by blinded assessors four times: at the start of the trial, immediately postintervention (6 months after randomisation), and at 3 and 6 months postintervention (9 and 12 months after randomisation, respectively). Predefined success criteria will be used to assess the feasibility of trial processes such as recruitment, attrition, stratification and intervention fidelity. Acceptability and perceived impact of the intervention will be explored qualitatively.

ETHICS AND DISSEMINATION

The study has been approved by Holland Bloorview Kids Rehabilitation Hospital's Research Ethics Board (Ref: 17-752). A knowledge translation planning template will be used to ensure our findings have maximum reach.

TRIAL REGISTRATION NUMBER

NCT03523806.

Solution-Focused Coaching in Pediatric Rehabilitation: Investigating Transformative Experiences and Outcomes for Families

AIMS

A qualitative study was conducted to investigate family experiences and outcomes of Solution-Focused Coaching in pediatric rehabilitation (SFC-peds).

METHODS

Two interviews (5 months apart) were conducted with nine sets of family members who had received SFC-peds, within the past 6 months, from therapists with 3-10 years of experience using the approach. Transcripts were analyzed using thematic analysis and a phenomenological approach.

RESULTS

Participants experienced a goal-oriented collaborative process, high engagement, enhanced capacity and community participation, and empowered mindsets. The therapy process was seen as a collaborative solution-focused conversation, situated in the client's world, and involving individualized and co-created goals and plans. SFC-peds provided families with a supportive, structured, and paced goal-setting process. Reported enhancements to capacity included child/youth skill development, enhanced parent skills, enhanced parent knowledge of their child and options, and changes in parenting. Increased community participation was also reported. Empowered mindsets involved increased confidence, increased self-efficacy and self-determination, and broadened perspectives and expectations.

CONCLUSIONS

The study provides evidence for the utility of SFC-peds and the importance of engaging families in a goal-oriented collaborative process. Implications concern greater understanding of transactional dynamics in therapy and real-world client change, and the need to develop measures of client/family resiliency.

A feasibility study using solution-focused coaching for health promotion in children and young people with Duchenne muscular dystrophy

PURPOSE

To evaluate the feasibility and acceptability of a coaching intervention (Solution-Focused Coaching in pediatric rehabilitation [SFC-Peds]) related to physical activity and diet in males with Duchenne muscular dystrophy.

METHODS

A pre-post design was employed. Participants had five coaching sessions over 8 weeks. The first session was face-to-face, followed by four virtual sessions. Feasibility criteria included recruitment rates, attrition, and intervention fidelity. The Canadian Occupational Performance Measure (COPM) and Goal Attainment Scaling (GAS) were employed to look at outcome trends. The acceptability was assessed using a survey.

RESULTS

Five males (11-19 years) participated. All feasibility criteria were met. Clinically significant increases were observed for GAS and COPM scores. Participants reported SFC-Peds to be acceptable. Broad barriers and facilitators to coaching success were identified.

CONCLUSIONS

A SFC-Peds intervention for health promotion is feasible and acceptable in children with DMD and their families. A rigorous efficacy study assessing SFC-Peds intervention is warranted.

Youth Engagement in Pediatric Rehabilitation: Service Providers' Perceptions in a Real-Time Study of Solution-Focused Coaching for Participation Goals

AIM

Client engagement is assumed to affect therapy outcomes. This study examined service providers' perceptions of youth engagement in solution-focused coaching sessions focusing on participation-oriented goals for youth with cerebral palsy.

METHOD

Service providers completed the Pediatric Rehabilitation Intervention Measure of Engagement-Service Provider version (PRIME-SP) at the end of each session of the brief solution-focused coaching intervention (3-5 sessions) for 10 youth.

RESULTS

Youth engagement was high yet fluctuated over the sessions. Service providers noted a range of components of engagement/disengagement (affective, cognitive, and behavioral) and related factors, including client states, components of behavior change (success or nonsuccess between therapy sessions, and pleasure with success), and service provider strategies. Four preliminary patterns involving engagement, client-reported success, and goal difficulty (personally achievable or dependent on others) appeared to be meaningfully related to quantitative measures of youth outcomes.

CONCLUSIONS

The study provides insights into the highly engaging nature of solution-focused coaching and the relational, co-constructed nature of the therapeutic interaction. The study indicates the utility of the PRIME-SP as a tool for recording observations of components of engagement and related factors that may be useful for clinical decisions about the use of engagement strategies and for general reflections on practice.

Exploring Parents' Perceptions and How Physiotherapy Supports Transition from Rehabilitation to School for Youth with an ABI

AIMS

To explore parents' perceptions of their youth's transition from rehabilitation to school following an Acquired Brain Injury (ABI) and how physiotherapy influenced the youth's participation and physical function during the transition.

METHODS

The study utilized phenomenological qualitative methodology using semi-structured interviews with 11 parents of youth 10 to 18 years of age recruited from one pediatric rehabilitation hospital in Ontario. Each interview was audiotaped, transcribed verbatim, and thematically analyzed.

RESULTS

Parents valued physiotherapy and highlighted potential areas of improved service delivery to promote participation in an active lifestyle during this transition. In addition to being parents, they had to assume new roles and responsibilities in order to motivate their youth to continue with therapy and physical activity and had to facilitate their participation in school, recreational and social activities.

CONCLUSION

For youth following an ABI, the transition back to school is complex and strategies should be supportive and responsive. Implications for physiotherapists include improved collaboration with community partners to motivate youth and promote physical activity; engage youth with their peers early in the rehabilitation process; and ongoing support for parents.

Cognitive Orientation to daily Occupational Performance (CO-OP): A New Approach for Children with Cerebral Palsy

AIMS

The results of a small single-case study series suggested that Cognitive Orientation to daily Occupational Performance (CO-OP) may be a successful approach for children with cerebral palsy (CP). Therefore a pilot randomized controlled trial was conducted with the following research questions-is CO-OP a feasible approach to use with children with CP, what are the effects of CO-OP when compared to usual practice, and is a larger study warranted?

METHODS

18 children between age 7 and 12 (nine in CO-OP group and nine in Current Usual Practice Approach (CUPA) group) received ten 1-hour sessions of intervention on average once per week at home. Primary outcome measures were the Canadian Occupational Performance Measure and the Performance Quality Rating Scale (PQRS). PQRS assessors were blind to group allocation and timing of assessment.

RESULTS

All children in the CO-OP group were able to learn the strategies and achieve their chosen goals, thus demonstrating the feasibility of the approach. Both approaches equally promoted skill acquisition and skill maintenance at follow-up. Effect sizes suggest that CO-OP may show some advantage for transfer and maintenance.

CONCLUSION

Based on these initial findings, further research is warranted.

It just feels weird!: a qualitative study of how children aged 10-18 years describe neuropathic pain

PURPOSE

The aim of this study was to explore how children aged 10-18 years describe their neuropathic pain (NP).

METHOD

This is a qualitative descriptive study using inductive content analysis. Semi-structured interviews were conducted with eight children, aged 10-18 years with varying diagnoses, who were experiencing NP.

RESULTS

All children were able to describe their NP using a variety of strategies, including use of literal and figurative language. While some sensory descriptors commonly reported by adults were used, descriptions of NP pattern and impact were also integral to their narratives. Children were able to differentiate NP from nociceptive pain. Parents clarified and gave context to pain reports.

CONCLUSIONS

NP is a complex experience necessitating consideration of the different ways that children describe their symptoms. Involvement of parents is invaluable to the process of taking a pain history with a child who is being screened for NP. Implications for Rehabilitation The findings of the study may inform the screening process for NP in children to facilitate earlier identification. Clinicians should consider the variety of ways that children may express their NP symptoms and the resulting impact. Clinicians should probe further when children report that symptoms are hard to describe or "weird". Presence of a parent during the child's pain assessment may assist with gathering a more complete picture.

Client-centred coaching in the paediatric health professions: a critical scoping review

PURPOSE

Coaching is mainstream in business and is expanding into paediatric health care. With the focus on evidence-informed health practice, it is imperative to identify the key active components of interventions. Coaching is by definition a complex intervention with numerous components. The purpose of this critical review is to determine how coaching is currently defined, its prevalence in paediatric health care services and the frequency of the active components of coaching and to consider the findings of research to date.

METHOD

A critical review of the literature was conducted. Inclusion/exclusion criteria were based on the International Coach Federation, which stipulates that coaching is a collaborative process that involves client-centred goal setting, facilitation, self-discovery and capacity building. Seventeen studies were selected for thorough review.

RESULTS

Throughout the literature, there was inconsistency in how coaching was defined. Studies included various components, but overall the literature lacked cohesion.

CONCLUSION

To advance the field, a list of components that foster client engagement was developed along with a comprehensive definition of coaching involving affective, behavioural and cognitive components and a path of research necessary to evaluate this complex intervention. Implications for Rehabilitation A comprehensive approach to coaching involves consideration of multiple components. A coaching approach can enhance engagement in rehabilitation interventions. The operationalization of holistic ABC coaching that encapsulates the important components, which are affective, behavioural and cognitive in nature.

Peer-coaching with health care professionals: what is the current status of the literature and what are the key components necessary in peer-coaching? A scoping review

BACKGROUND

Peer-coaching has been used within the education field to successfully transfer a high percentage of knowledge into practice. In recent years, within health care, it has been the subject of interest as a method of both student training and staff continuing education as well as a format for knowledge translation.

AIMS

To review the literature from health care training and education to determine the nature and use of peer-coaching.

METHOD

Due to the status of the literature, a scoping review methodology was followed. From a total of 137 articles, 16 were found to fit the inclusion criteria and were further reviewed.

RESULTS

The review highlights the state of the literature concerning peer-coaching within health care and discusses key aspects of the peer-coaching relationship that are necessary for success.

CONCLUSIONS

Most research is being conducted in the domains of nursing and medicine within North America. The number of studies has increased in frequency over the past 10 years. Interest in developing the potential of peer-coaching in both health care student education and continuing clinical education of health care professionals has grown. Future directions for research in this quickly developing area are included.

Writing forces associated with four pencil grasp patterns in grade 4 children

OBJECTIVE. We investigated differences in handwriting kinetics, speed, and legibility among four pencil grasps after a 10-min copy task. METHOD. Seventy-four Grade 4 students completed a handwriting assessment before and after a copy task. Grip and axial forces were measured with an instrumented stylus and force-sensitive tablet. We used multiple linear regression to analyze the relationship between grasp pattern and grip and axial forces. RESULTS. We found no kinetic differences among grasps, whether considered individually or grouped by the number of fingers on the barrel. However, when grasps were grouped according to the thumb position, the adducted grasps exhibited higher mean grip and axial forces. CONCLUSION. Grip forces were generally similar across the different grasps. Kinetic differences resulting from thumb position seemed to have no bearing on speed and legibility. Interventions for handwriting difficulties should focus more on speed and letter formation than on grasp pattern.

Effect of Pencil Grasp on the Speed and Legibility of Handwriting in Children

OBJECTIVE. Pencil grasps other than the dynamic tripod may be functional for handwriting. This study examined the impact of grasp on handwriting speed and legibility.

METHOD. We videotaped 120 typically developing fourth-grade students while they performed a writing task. We categorized the grasps they used and evaluated their writing for speed and legibility using a handwriting assessment. Using linear regression analysis, we examined the relationship between grasp and handwriting.

RESULTS. We documented six categories of pencil grasp: four mature grasp patterns, one immature grasp pattern, and one alternating grasp pattern. Multiple linear regression results revealed no significant effect for mature grasp on either legibility or speed.

CONCLUSION. Pencil grasp patterns did not influence handwriting speed or legibility in this sample of typically developing children. This finding adds to the mounting body of evidence that alternative grasps may be acceptable for fast and legible handwriting.

Changes in kinetics and kinematics of handwriting during a prolonged writing task in children with and without dysgraphia

Handwriting difficulties or dysgraphia have a profound impact on children's psychosocial development, and yet, 10-30% of school-aged children are reported to experience difficulties mastering this skill. Several studies have examined the nature and biomechanical underpinnings of handwriting difficulties in children with and without dysgraphia. While the majority of these studies have considered short handwriting activities involving a sentence or a paragraph, handwriting quality and speed are reported to vary with the length of the writing task. Further, it is suggested that the biomechanics of handwriting also evolve over extended writing periods, and that these changes may be distinct between children with and without dysgraphia. The nature and specificity of these biomechanical alterations remain unknown. To address this knowledge gap, we examined changes in writing speed, grip forces on the pen barrel, and normal forces on the writing surface, over the course of a 10-min writing task, in a large cohort of 4th grade children with and without dysgraphia. Horizontal stroke speed, grip force and normal force increased over time while vertical stroke speed decreased in all children. These biomechanical changes may be attributable to physical and psychological fatigue and the corresponding compensatory processes invoked by the motor system.

Grip force variability and its effects on children's handwriting legibility, form, and strokes

A comprehensive understanding of the underlying biomechanical processes during handwriting is needed to accurately guide clinical interventions. To date, quantitative measurement of such biomechanical processes has largely excluded measurements of the forces exerted radially on the barrel of the writing utensil (grip forces) and how they vary over time during a handwriting task. An instrumented writing utensil was deployed for a direct measurement of kinematic and temporal information during a writing task, as well as forces exerted on the writing surface and on the barrel of the pen. The writing utensil was used by a cohort of 35 students (19 males), 16 in first grade and 19 in second grade, as they performed the Minnesota Handwriting Assessment (MHA) test. Quantitative grip force variability measures were computed and tested as correlates of handwriting legibility, form, and strokes. Grip force variability was shown to correlate strongly with handwriting quality, in particular for students classified by the MHA as nonproficient writers. More specifically, static grip force patterns were shown to result in poor handwriting quality and in greater variation in handwriting stroke durations. Grip force variability throughout the writing task was shown to be significantly lower for nonproficient writers (t-test, p<0.01) while the number of strokes and per-stroke durations were shown to be higher (p<0.03). The results suggest that grip force dynamics play a key role in determining handwriting quality and stroke characteristics. In particular, students with writing difficulties exhibited more static grip force patterns, lower legibility and form scores, as well as increased variation in stroke durations. These findings shed light on the underlying processes of handwriting and grip force modulation and may help to improve intervention planning.

The Clinical Utility of a Tool for Optimising Written Productivity

Occupational therapists working with children with handwriting issues lack a standard framework for selecting treatment activities. This study investigated the utility of a decision-making guide, the Tool for Optimising Written Productivity (TOW-P). In the study, 14 occupational therapists used the TOW-P to guide the selection of interventions for 60 children with handwriting issues. The therapists completed two questionnaires about the usefulness of the tool. Feedback was used to modify the structure and format of the tool. The results indicated that the TOW-P provides a clinically useful framework to assist therapists in the selection of appropriate intervention strategies for children with written productivity issues.

Movement-to-music computer technology: a developmental play experience for children with severe physical disabilities

Children with severe physical disabilities often lack the physical skills to explore their environment independently, and to play with toys or musical instruments. The movement-to-music (MTM) system is an affordable computer system that allows children with limited movements to play and create music. The present study explored parents' experiences of using the MTM system with their children. A qualitative methodology employing in-depth interview techniques was used with six mothers and their children. The themes extracted from the data were organized under two main concepts of the International Classification of Functioning, Disability, and Health (ICF) (WHO, 2001) framework. The results showed that the MTM expanded horizons for the child along the ICF health dimensions and the MTM had a positive impact on ICF environmental determinants of health. The small sample size should be noted as a limitation of this study. Further research should be carried out with a larger sample of children with restricted mobility to obtain a better understanding of the impact of MTM technology on children's psychosocial development.

A Novel Instrument for Quantifying Grip Activity During Handwriting

OBJECTIVE

To describe and exemplify a noninvasive instrumentation system that uniquely records grip forces exerted on the barrel of the writing utensil along with typical temporal and kinematic parameters.

DESIGN

Exploratory case series.

SETTING

A tertiary care, pediatric rehabilitation hospital.

PARTICIPANTS

Convenience sample of 6 primary school children with spastic hemiplegic cerebral palsy (CP) with documented fine motor difficulties and 6 children with no known handwriting difficulties.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Grip and normal forces during handwriting.

RESULTS

The instrumentation revealed nontrivial correlations between normal and grip forces (0.55 +/- 0.16), a temporal delay between normal and grip forces (97.7 +/- 16 ms), and a consistent grip-to-normal force ratio (4.3 +/- 1.5), across all participants. Grip force distributions agreed intuitively with qualitative observations of individual grasps of the writing utensil. Further, 5 new parameters derived from grip force measures statistically differentiated between able-bodied children and those with hemiplegic CP.

CONCLUSIONS

The proposed instrumentation provides new insight into grip and normal force coordination and has the potential to uncover discriminatory grip force characteristics between writers with and without handwriting difficulties. Further study with larger populations is required to define functional ranges for the new grip measures.

Caregiving process and caregiver burden: conceptual models to guide research and practice

BACKGROUND

Parental care for a child with a developmental disability is an enormous responsibility, one that can far exceed that of typical parental care. While most parents adapt well to the situation of caring for a child with a disability, some do not. To understand parents' adaptations to their children's disabilities, the complex nature of stress processes must be accounted for and the constructs and factors that play a role in the caregiving must be considered.

DISCUSSION

Evidence suggests that there is considerable variation in how caregivers adapt to their caregiving demands. Many studies have sought to qualify the association between caregiving and health outcomes of the caregivers. Contextual factors such as SES, child factors such as child behaviour problems and severity of disability, intra-psychic factors such as mastery and self-esteem, coping strategies and social supports have all been associated with psychological and/or physical outcome or parents or primary caregivers. In reviewing these issues, the literature appears to be limited by the use of traditional analytic approaches which examine the relationship between a factor and an outcome. It is clear, however, that changes to single factors, as represented in these studies, occur very rarely even in the experimental context. The literature has also been limited by lack of reliance on specific theoretical frameworks.

SUMMARY

This conceptual paper documents the state of current knowledge and explores the current theoretical frameworks that have been used to describe the caregiving process from two diverse fields, pediatrics and geriatrics. Integration of these models into one comprehensive model suitable for this population of children with disabilities and their caregivers is proposed. This model may guide future research in this area.

The development of the tool for optimizing written productivity (TOW-P)

Many school-aged children experience difficulties in written productivity, which result in a large number of referrals for school-based Occupational Therapists (OTs). Health care practitioners are being called upon to establish consistent practice, yet there are presently no guidelines to facilitate consistency in this clinical area. The Tool for Optimizing Written Productivity (TOW-P) was developed to assist OTs in decision-making regarding intervention selections for this population. A pilot study and a province-wide survey yielded specific frequencies of intervention for different written productivity issues that can be used to guide a therapist's selection of interventions.