Integrated Therapy Service for Children and Young People Frances Rowe, Service Manager

Integrated Therapy Service for Children and Young People

Frances Rowe, Service Manager

History of the ITS•Before October 2009 – 4 separate Trusts provided Paediatric

Speech and Language Therapy, Occupational Therapy and Physiotherapy – patchwork of provision, different models of delivery and waiting times

•October 2009: One Integrated Therapy Service commissioned

•Provides: Integrated SLT, OT and PT to all of the county – for babies, children and young people aged 0 – 19 years

•Delivered in: ITS clinics, Children’s Centres, pre-schools, mainstream and special schools, family homes, hospital wards and outpatient clinics

• Integrated Area Teams: Taunton, Bridgwater, Yeovil and Wells

Challenges – and responses

•Referral process: GP Choose and Book system a poor fit with the service – concerns and complaints

Response: consultation with users and stakeholders on alternative model

Outcome: May 2011: Single Point of Access – in-house referral point

Telephone Advice Line, 09.00 – 12.00, four mornings per week, staffed by SLT, OT and PT. Professional advice

and guidance, potential for acceptance of referral

Successful and busy!

Challenges – and responses

•35% rise in referrals from 2009 – increased pressure on the service without additional funding

Response: - Improved referral forms, specific information requested- Careful triage of referrals – ensuring appropriateness- Very close monitoring of referral rates & assessment clinics - Revision of reporting paperwork- Personalised care planning, evaluation of outcomes- Discharge if intervention not needed, re-referral guidance- Increased skill mix, flexible workforce moving where required

Outcome: Longest wait for the service reduced from 2 years to 12 weeks and below by end of March 2012, despite increase in referrals

Next steps...

Aim: For families and the wider children’s workforce to have the knowledge, skills and confidence to:

- prevent problems increasing- support children with lower levels of need in daily

life - identify those children who require specialist

assessment & support

Response: Fact File for Early Years, 0 – 4 years

Fact File for School Age, 5 – 19 years

Fact File for Early YearsSection One: Introduction

• The Fact File for Early Years contains information on:

• How to help promote children’s development in the areas dealt with by Speech and Language Therapy, Occupational Therapy and Physiotherapy

• How to identify common and acceptable variations in young children’s development

• How to decide which children may need additional support to promote their development

• Practical Advice Sheets which you can also share with parents • How and when to refer for specialist assessment by the

Integrated Therapy Service

Fact File for Early YearsGeneral principles of the Early Years Fact File

• Many children and young people will show difficulties at some point in their development – most will progress given the right environment and simple strategies used by those around them

• The Fact File for Early Years is intended to give practitioners information and confidence to be able to meet children’s needs and advise their parents/carers

• Early identification of children needing extra support is vital – this does not always mean early referral

• A small proportion of CYP will require specialist support from the ITS to enable them to carry out the activities that they need or want to do. This Fact File for Early Years will help you to identify which children or young people may require this specialist support

Fact File for Early Years• Section Two: Factors affecting children’s development and

what you can do to help

It is entirely normal for children to develop at different rates. You only need to be concerned about significant differences in obtaining expected milestones.

Children develop at different rates based on several factors which include those that are environmental, cultural and innate. We can influence some of these but others are out of our control.

• A child’s temperament• A child’s general health• Premature babies – more likely to show variations in their

development• A child’s play experiences

Fact File for Early Years

What you can do to help children’s early development

0 – 12 months

12 months onwards


• Section Three: Common problems and acceptable variations in typical development

Common variations in gait (walking patterns)

There is a wide range of normal variation in children’s walking patterns. The following areas are often a cause for concern to parents and carers but are all normal variations that do not require physiotherapy assessment.

e.g. Flat feet, intoeing, bow legs, knock knees etc.


Section Four: Problems you may see and what to do

If a child loses a skill they had already developed, this is a cause for concern. You should refer them to their GP and to the Integrated Therapy Service (ITS).

If the action is to contact the ITS for advice, please use the Telephone Advice Line.

09:00 to 12:00 in the morning Monday, Wednesday, Thursday and Friday

(excluding Bank Holidays)

0303 033 3002

Fact File for Early YearsProblems you may see and what to do – 1 month

Observations Action See Advice Sheets

(Section 5)

Baby turns their head to the same side for the majority of their waking hours.

Follow Advice Sheet

If no improvement after 1 month, refer to the ITS

Tummy Time

Head flattening on the back or one side of the baby’s head. NB. Many babies have mis-shapen heads following delivery. This should correct itself as the baby develops.

Follow Advice Sheet

If no improvement after 1 month, refer to the ITS

Tummy Time

Fact File for Early YearsProblems you may see and what to do – 9 months

Observations Action See Advice

Sheets (Section 5)

Baby lifts their legs up when placed in a standing position.

Follow Advice Sheet

If no improvement after 2 months, refer to the ITS

Helping a Baby Develop Standing and Stepping

Baby dislikes physical play with an adult (e.g. being bounced / rough and tumble play).

Follow Advice Sheet


Rough and Tumble Play

Baby has difficulty coping with solids e.g. gagging, choking on lumps.

Contact the child’s GP or Health Visitor for advice and contact the ITS if needed

Fact File for Early YearsProblems you may see and what to do – 2 years


(Section 5)

Child is unable to walk independently

Refer to the ITS

Child refuses to try new foods. Becomes faddy at mealtimes.

Follow Advice Sheet

If no improvement after 6 months, contact the ITS

Trying new foods

Child shows little or no interest in communication and interaction. Little pretend play, poor attention. Is not responding to simple instructions e.g. ‘Where’s your coat?’

Refer to the ITS

Follow Advice Sheet

Use Somerset Total Communication strategies

Toddler Talk

Fact File for Early YearsProblems you may see and what to do – 3 years


(Section 5)

Child is unable to undress. Follow Advice Sheets


Dressing Skills Dressing Skills Additional Guidance 1 & 2

Child has difficulty with hand skills in comparison to peers of a similar age (e.g. threading, crayon skills).

Follow Advice Sheets


Developing Hand Skills Pre-writing Activities

Child uses only 1 - 2 word combinations, or is echoing adult language or learnt phrases, or has word order which is unusual.

Refer to the ITS

Follow Advice Sheet

Pre-school Talk

Fact File for Early YearsProblems you may see and what to do – 3 1/2 – 4 years


(Section 5)

Child has difficulty with balance and gross motor skills in comparison with peers of a similar age e.g. falls frequently, is unable to jump with two feet together



Helping a Child Develop their Balance

Child is unable to attempt fastenings such as buttons and zips



FastenersDeveloping Hand Skills

Child’s speech is difficult to understand or a limited range of sounds used

Refer to the ITS

Follow Advice Sheet

Helping Children with Unclear Speech

Fact File for Early YearsSection Five: Advice Sheets for parents, carers and pre-school

settings

Contents Ref no Page

Baby talk CYP ITS ASEY001 33

Basic communication strategies CYP ITS ASEY002 35

Coping with lumps CYP ITS ASEY003 36

Developing cutlery skills CYP ITS ASEY004 40

Developing hand skills CYP ITS ASEY005 43

Fact File for Early YearsAdvice sheets for parents, carers and pre-school

settings

• Baby talk • Basic communication strategies • Coping with lumps • Developing cutlery skills • Developing hand skills • Dressing skills • Fasteners • Finger feeding • Helping a baby develop rolling and sitting • Helping a baby develop standing and stepping• Helping a child develop their balance


• Helping children with unclear speech • Learning to ride a tricycle • Messy play • Pre-school talk • Pre-writing activities• Rough and tumble play• Stammering• Talipes or club foot• Toddler talk• Trying new foods• Tummy time• Using both hands together

Fact File for Early YearsDeveloping hand skills – why do some children find this

difficult?

You have been directed to this Advice Sheet because your child is having difficulty developing their fine motor / hand skills. These are the skills needed to complete activities like feeding, dressing, playing or drawing. There are many reasons why children have difficulty developing these skills including movement problems, learning difficulties or developmental delay.

If you see no improvement after 6 months of using this Advice Sheet, please contact the Integrated Therapy Service for further advice

What you may see

Strategies and Advice

Fact File for Early YearsSection Six: The Integrated Therapy Service and how to refer

• What is the Integrated Therapy Service for Children & Young People?• Staff Teams – roles of SLTs, OTs and PTs• Area Bases – contact details• Who can refer?• How to make a referral• Telephone Advice Line• Making a written referral• Triaging referrals• Assessment• Intervention• Discharge


Appendices

• Appendix 1 ‘Integrated Therapy Service Referral form’

• Appendix 2 ‘Additional Information to Support Occupational Therapy Referral’

• Appendix 3 ‘Every Child a Talker’ monitoring form

Fact File for School AgeSection One: Introduction

• The Fact File for School age contains information on:

• Typical development of children and young people in the areas that fall within the expertise of SLT, OT and PT

• How to identify common and acceptable variations in CYP’s development • How to decide which children and young people may need additional

support to promote their development. • Practical Advice Sheets which you can also share with parents/carers • When and how to refer for specialist assessment by the ITS

• General principles of the School Age Fact File – as for Early Years

Fact File for School AgeSection Two: Developmental milestones. 4 – 5 Years

(Reception)

Movement Hand & Finger Skills

Language & Social Communication

•Uses playground/gym equipment independently (climbing frame with ladder slide, low balance beams, swings – may not be able to initiate the swing)

•Stands on one foot for 5 seconds or more

•‘Gallops’ along for 4 – 5 metres

•Hops on one foot 5 or

more times

•Copies square

•Draws a person with two to four body parts, includes head, legs, trunk and usually arms and fingers

•Holds instrument with proper tension and grasp (scissors, pencils, pen, paintbrush)

•Produces speech which is mostly intelligible

•Produces most consonant sounds but ‘r’, ‘th’, ‘l’, ‘ch’ and ‘j’ may still not be correct

•Simplifies some sound combinations e.g. ‘tain’ for ‘train’, ‘boon’ for ‘spoon’

•Words may be less clear in sentences than spoken singly

•Attention skills are generally two-channelled i.e. the child can do a task while listening to a simple instruction

Fact File for School AgeDevelopmental milestones. 5 – 6 Years (Year 1)

Movement Hand & Finger Skills

Language & Social Communication

•Stands on one foot for 10 seconds

•Skips along for 4 – 5 metres

•Walks around classroom/ school avoiding collision with stationary objects/people

•Carries objects around classroom/school avoiding collision with stationary objects/people

•Can cut/draw/trace with accuracy and precision

•Uses blocks, beads, puzzle pieces to complete appropriate tasks

•Copies triangle and other geometric patterns

•Produces most consonant sounds but ‘r’ and ‘th’ may not be established

•Some words may be hard to understand in connected speech but clearer if repeated

•Some long words with difficult sound combinations may show errors

•Two-channelled attention should be well established across a variety of situations

•Many children can remember a sequence of 5 digits

Fact File for School AgeDevelopmental milestones. 6 – 7 Years (Year 2)

Movement Language & Social Communication

By this age children should have acquired most of their developmental milestones for movement

•Basic motor skills acquired – improvement in speed and skills of tasks should be observed

•Able to use ball skills whilst running at speed and changing direction

•Accuracy with aim and throwing

whilst on the move

As for children aged 5 – 6 years (Year 1), plus:

•Uses adult-like grammar and word order in their oral language

•Has learned the ‘rules’ of conversational etiquette (e.g. “Excuse me”)

•Can start and sustain conversations over multiple turns (five or more) with two or more partners

•Produces stories that centre around a theme and contain a logical chain of events

•Becomes more explicit in their language when they

recognise that the listener is not understanding

Fact File for School AgeDevelopmental milestones. 8 – 11 Years (Key Stage 2)


Milestones are

achieved.

•Has most speech sounds and sound combinations including ‘th’ and ‘r’ unless errors are related to dialect

•Certain sounds may be produced in a slightly unusual way giving a different quality to the child’s speech, e.g. a lisp, although this will not affect intelligibility

•Multisyllabic words may contain the occasional mistake

•Many children can remember a sequence of 6 – 7 digits

•Understands questions requiring inference or prediction e.g. ‘How do we know he is feeling sad?’ or ‘What could he have done?’

Fact File for School AgeDevelopmental milestones. Into the teenage years (Key Stages 3 and 4)


Milestones are

achieved.

•Speech can seem to deteriorate in clarity and become more mumbled

•Boys’ voices deepen

•Understands jokes and riddles based on ambiguity which is embedded in the structure of sentences rather than in individual words

•Able to extract key information from extended amounts of verbal information

•Knowledge of grammatical rules reaches adult level

•Develops knowledge of how stress changes the meaning of what is said

•Able to vary structure of language for different verbal and written purposes

Fact File for School Age

Section Three: Common problems and acceptable variations in typical development

• Common variations in speech and language development

• Common variations in children using their right and left hands for different tasks

• Common variations in dressing skills

• Common variations in gait (walking patterns)

Fact File for School Age• Section Four: Problems you may see and what to do

The Problems Table, on the next pages, will help direct you to Advice Sheets relevant to your concerns

How to use the Problems Table:

• Identify your main concern

• Look through the observations column on the left to find the most appropriate description of the area of difficulty

• Follow this row along to the right to find the suitable Advice Sheet or Sheets, highlighted by a large dot

Fact File for School AgeSection Four: Problems you may see and what to do

• Some observations may have more than one recommended Advice Sheet.

• Look at each Advice Sheet and either choose an individual Sheet or combine activities from two. This decision will depend on your observations of the child.

• The Advice Sheets specify a time period for the activities to be implemented. After this time, if no improvement has been noted, please contact the Integrated Therapy Service by calling the Telephone Advice Line.

• If your concern or observation is not listed on the table, please contact the Integrated Therapy Service by calling the Telephone Advice Line.

Fact File for School AgeProblems you may see and what to do

Observations

Speech sounds: 111

Speech sounds immature and may be unintelligible

.


Observations

VerbalComprehension: 121

Auditory processing: 31

Does not understand/ process verbal instructions

. .


Observations

Core stability: 48

Flexible joints: 68

Maximising attention: 83

Can’t maintain an upright sitting posture for more than 10 minutes

. . .


Observations

Crossing the midline: 53

Hand gym for older child: 71

Bilateral integration: 39

Difficulty coordinating two hands together for an activity

. . .

Fact File for School AgeSection Five: Advice Sheets for schools, parents and carers

Contents Ref no Page

Auditory processing CYP ITS ASSA001 31

Balance CYP ITS ASSA002 34

Ball skills CYP ITS ASSA003 38

Bilateral integration CYP ITS ASSA004 39

Calming CYP ITS ASSA005 42

Fact File for School AgeAdvice sheets for schools, parents and carers• Auditory processing • Balance • Ball skills • Bilateral integration • Calming • Confidence and self esteem • Core Stability • Crossing the midline • Developing fine motor skills • Dressing skills • Expressive language • Fasteners• Flexible (hypermobile) joints • Hand gym for the older child • Handwriting

Fact File for School Age• Letter and number reversals • Maximising attention • Motor planning • Organisational strategies for school and home • Pelvic stability • Perceptual skills • Pragmatics or social communication skills • Scissor skills • Shoes and socks • Shoulder stability • Speech sounds • Stammering • Transitions and settling to task • Tying shoelaces • Verbal comprehension (understanding language)• Vocabulary •


Expressive language

• Expressive language is the way we put words together into phrases and sentences to express meaning. It includes aspects such as word order, use of small function words such as 'of', and 'are' and word endings, for example those that signal plurals and different verb tenses.

• Expressive language development follows a recognised sequence. If

a child’s expressive language development is following this typical progression but at a slower rate than their peers, they have an expressive language delay. If they are not following this progression, their expressive language is considered to be disordered.


Expressive language

• If you have used this Advice Sheet and not seen improvement after 3 – 4 months, please contact the Integrated Therapy Service.

What you may see

Strategies and advice

Suggested resources


Section Six: The Integrated Therapy Service and how to refer

As for the Fact File for Early Years


Appendices

• Appendix 1 ‘Integrated Therapy Service Referral form’

• Appendix 2 ‘Additional Information to Support Occupational Therapy Referral’

• Appendix 3 ‘Communication Competencies in School’

Next steps...Aim: To ensure that those children and young people

who have complex, high level needs that only a qualified therapist can assess, advise on or treat...and who it is predicted will be able to respond to this specialist input...receive the help they need, when they need it

Response: Redefining the core service – care pathways and levels of intervention

Further development and extension of the ITS Therapy Guidance Sheets for assessed and diagnosed conditions

...work in progress

Next steps...Aim: For partner services, e.g. schools/school clusters to

have the opportunity to increase levels of therapy support and staff expertise and thereby further improve outcomes for children and young people

Response: Prospectus of Additional Therapy Services available for commissioning:

Additional levels of therapyGroup workTraining for staffBespoke consultancyDrop-in clinics for staff and familiesScreening

Additional therapy services from the ITS

In a unique position to provide high quality additional services

• Working to NHS professional and clinical standards• Three therapies, integrated• Working alongside the core service, eliminating reduplication

and miscommunication• Long experience of working within settings in Somerset• Familiarity with the county statutory processes• Well established joint working with Education services• Close working with other Health services• Safe, evidence-based practice – CPD, supervision, appraisal• HPC registered and monitored therapists• Trained and supervised therapy support practitioners• Regular safeguarding supervision• Value for money – commissioning of skill mix teams

Additional therapy services

Commissioning of additional therapy services for Speech and Language Therapy, Occupational Therapy, Physiotherapy will help you to:

– Enhance early identification and support

– Raise educational attainment

– Improve behaviour

– Increase children and young people’s life chances

Documents

Integrated Therapy Service for Children and Young People Frances Rowe, Service Manager