SPHSC 543 MARCH 5, 2010 Questions?. TREATMENT Assessment will have identified if there is a problem and what the problem is. Any treatment plan

SPHSC 543MARCH 5, 2010

Questions?

TREATMENT

Assessment will have identified if there is a problem and what the problem is.

Any treatment plan must meet three criteria:

should be safe

should strive to maintain optimal nutrition

should be farsighted

TREATMENT

What the child needs to bring to the treatment process:

… Functioning GI system

… Stable pulmonary system

… Developmentally appropriate oral sensorimotor and feeding skills

Look at relationships between oral and respiratory systems, and child’s learning and communication strategies.

TREATMENT

What influences tone/movement patterns?

Look at limiting movement patterns and look for automatic reflexes that can be elicited to promote normal patterns of movement.

Family dynamics

… Important in evaluation and treatment planning

BASIC PRINCIPLES

Facilitate normal patterns of movement and normalize ability to accept/integrate input – visual, auditory, vestibular, taste and temperature

Include treatment into typical ADLs of childhood

… Mealtime

… Toothbrushing

… Bathing

… Dressing

… Play

Remember: The ultimate goal may not be achieving full oral feeding

… Success may include whole or part nutrition by non-oral means

TREATMENT

Can be direct

… Oral “exercises”

… Non-nutritive oral stimulation (NNOS)

… Therapeutic tastes

Can be indirect

… Alterations in

Environment

Positioning

Seating

Communication signals

Food consistency

TERMINIOLOGY

Feeding Therapy

Implies primary goal is oral feeding

Oral Sensorimotor Treatment

… Primary goal is coordinated movements of the mouth, respiratory and phonatory systems for communication and oral feeding

… Focus is on the ‘total’ child

TREATMENT VS MANAGEMENT

Treatment

… Goal is to improve a problem or condition underlying feeding dysfunction

Management

… Underlying cause of problem cannot be modified by treatment techniques at this time

… Address symptomatology to maintain health and nutrition

… “Buy time” until the underlying problem changes through maturation or medical improvement

OPTIONS FOR TREATMENT/MANAGEMENT

Medical techniques

… Medications, O2, NGT

Surgical techniques

… Repair of anatomical anomalies

… G Tube placement

Modification of feeding situation

… State

… Posture and position

… Swallowing

… Oral-motor control

… Coordination of SSB

… Tactile responses

GETTING READY

Prepare the infant

… State, tone and movement, tactile responses

Prepare the environment

… Visual stimuli

… Noise

… Temperature

Prepare the feeder

STATE

Feeding possible in drowsy/semi-dozing, quiet alert and active alert states

Hypersensitive, easily disorganized –drowsy versus active/alert state

Sleepy –very alert

Look at patterns of states, transitions between states, and stability of state

May need to modify environment during feeding

STATE

Tactile

… Alerting effect

… Often combined with movement

Temperatures

… Cooler

… Change clothes/diaper

… Unbundle

… Cool washcloth

AROUSAL

From sleepy/semi-drowsy to calm, alert

… Variable, not predictable, not rhythmic

Movement

… Can have a strong alerting effect

… Picking up baby, being in an upright position

… Rocking from side-to-side

Auditory

… pitch, tone, rhythm, quiet to louder, lively music

CALMING

Irritable, crying, hyperstimulated, disorganized, easily startled

Containment and rhythmicity are key

Tactile

… Firm, deep pressure and containment

Swaddling

… Physical containment

… Tonic, disorganized

… Frequent, firm proprioceptive and deep pressure contact

CALMING

Swaddling continued

… Arms together in midline, hips flexed, head covered

… Use well-flexed, vertical position

… Use body – posture and firmness of holding

… Infant massage

Movement

… Rhythmic, constant, predictable

… Try different rhythms

… Bouncing, rocking when swaddled

CALMING

Auditory

… Decreasing auditory input

… White noise, rhythmic, repetitive music

… Minimal speech

Tone, posture, position

… Balance between flexor and extensor

… Movements should be smooth and well modulated

… Alignment of head, neck and trunk are crucial

OPTIMAL FEEDING POSITION

Overall flexion

Orientation of head and extremities about the midline

Shoulders symmetric and forward

Arms flexed and toward body midline

Hips flexed from 45-90 degrees

SEATING/POSITIONING

Look at shoulder girdle, trunk, hips/pelvis, sitting base, stability of feet, eye contact/control, head control and spinal mobility

… Soft chair (bean bag) or foam/towel between shoulders – retraction

… Vest attached to chair, foam/towels on table – protraction

… Hold shoulders down

… May need trunk supports/pads

… Rolled towels under knees – posterior pelvic tilt

… Lumbar spine – anterior pelvic tilt

… Seat depth, width, angle

SEATING/POSITIONING

… Sitting base – wider (pommel) more stable; hip adductor to bring knees together

… Foot rest, towels, blankets, books

… Eye control/contact – supine – no demands for head control.

… Feeder should be at eye level

… Head/spine – must look at hips, pelvis, trunks and shoulder girdle first. Slight recline, head rest, chin tuck

… Abdomen – build muscle tone and control. Improve breathing and postural adjustments during mealtimes

SEATING/POSITIONING

Freedom of movement – spinal movement and changes movement around body axis

FEEDING POSITIONS

En face

… Maximal head control is possible, harder to provide trunk support

Supine in lap

… Hard to control side-to-side head movement

… Hands free tube feeders, pacifier for NNS

… Can be inclined

Sidelying on lap

… Trunk straight and well supported

… Helps retracted tongue come forward

FEEDING POSITIONS

Head in greater flexion

… Facilitate sucking and lip seal

… Compensate for poor laryngeal elevation

Head in slight extension

… Assists breathing

SWALLOWING

Depends on where the problem is:

… Poor organization of bolus in oral phase

… Delayed swallow reflex initiation

… Abnormal pharyngeal phase

… Incoordination of pharyngeal/esophageal peristalsis

IMPROVE BOLUS FORMATION

Problem with tongue control

… Provide single bolus then pause to allow organization

… Small boluses (0.1-0.5 cc, 1 Tbsp to 2 oz)

… Allows establishment of suck

… Thicken liquid

Moves slower, easier for tongue to maintain bolus

DELAYED SWALLOW REFLEX INITIATION

Thermal stimulation

… Triggers faster swallow reflex in adults

… Refrigerator-chilled liquids or semisolids

… May diminish over subsequent swallows

If non-orally fed – may suck on frozen pacifier

Thicken liquid/pureed foods

Improving laryngeal closure

… Forward head flexion/chin tuck

… Angled bottle, cut out cup, straw

ASPIRATION AFTER THE SWALLOW

Usually secondary to residue

… Decreased pharyngeal peristalsis

… Dysfunction of the CP muscle

… Inadequate pressure gradients

Noisy, wet-sounding breathing that is worse following feeding

Modify food texture

Encourage “dry” swallows

Palatal trainer

DECISION-MAKING AND ASPIRATION

Degree of swallowing dysfunction

Amount of aspiration

Response to treatment

Underlying pulmonary status

Tracheostomy

Therapeutic feeds

Full PO with modifications

GER

Non-oral restriction decreases GER but may still have….

… Ascending aspiration

… Need to increase/maintain oral skills

… Provide therapeutic feeds

ORAL-MOTOR CONTROL

Hypotonia – poor stability and abnormal control

Need to ‘wake up’ or ‘alert’ CNS

… Tapping

… Vibration

… Quick stretch

Masseter and buccinator muscles

Lips/tongue

ORAL-MOTOR CONTROL

Hypertonia – abnormal movement and may lead to abnormal alignment

Neurological insult or abnormality, stress

… Preparatory movements

Handling

Body alignment

… Firm pressure

… Shaking/vibrating

… Tongue retraction

… Environmental management

TONGUE

Neck extension – functionally pulls tongue into retracted position

May be hypertonic or passively retracted

May be actively seeking point of stability (micrognathia)

Postural support – improve head/neck alignment

Handling – normalize tone, neck/shoulders

Modify tone in tongue

… Finger in midline

… Shaking, jiggling, tapping, stroking, vibrating

Longer nipple

TONGUE

Bunched, humped, retracted, hypotonic

Lacks central groove

Get tongue forward

Downward pressure to midline

Stroking forward with downward pressure

Firm straight nipple with cross-cut

TONGUE

Tongue-tip elevation – pressed against hard palate, distal to alveolar ridge

Common in preemies – may be a means of stabilization

Postural support

Preparatory handling

Quick swiping or vibration

Downward pressure

Assist with mouth opening

… Stimulation to lips

… Downward pressure on jaw

TONGUE

Protrusion – sits on lower lip below nipple and interferes with lip seal

Hypotonia/weakness/increased tone

Neck extension

Postural support – neutral or slightly flexed

Preparatory handling to reduce tone

Sensory input – firm tapping

Firm, downward pressure to midline

Firm straight nipple

Facilitate lip activity

POOR MOUTH OPENING

Poor arousal

Neurologic insult

Prepare state

Elicit rooting reflex

Assist mouth opening – gentle downward pressure

Inhibit jaw clenching – vibration, very small-range, low amplitude side-to-side movement

Touch/pressure to gums

WEAK SUCK

Ineffective feeding

Overall weakness, medical/nutritional compromise, immaturity, myopathies, respiratory/endurance

Provide oral stability – optimal positioning, firm cheek/jaw support, traction on nipple

Increasing flow rate (with caution)

JAW MOVEMENT

Excessive – no stable base for tongue, lip seal may be compromised

Develop stable base for jaw, slightly tucked chin position, develop neck flexor musculature

Preemies – often have jaw instability. Poor developed tone/bulk in oral-facial mm, minimal active neck flexion, neck hyperextension common

Neurologically-based hypertonicity – poorly balanced control between opening and closing mm. May lead to strong downward thrust of jaw

Neck hyperextension – could be immature development of neck flexion, abmormal mm tone or stress

ABNORMAL TONGUE MOVEMENT

Attempts to use marked jaw depression to create negative pressure suction

Postural support – neck/head alignment key. Don’t allow neck hyperextension. Head in neutral or slight flexion will provide additional positional stability to jaw.

External support – firm pressure under jaw. Keep pressure distal and under mandible, proximally will be under base of tongue could interfere with sucking.

ABNORMAL TONGUE

Increased neck flexion – if doesn’t respond well to external support, bring head into strong neck flexion. Help grade jaw movement. Continually monitor respiratory status.

Handling techniques to reduce overall mm tone

May need to target tongue

LIP SEAL

Negative pressure reduced or broken intermittently

Smacking/kissing, excessive fluid loss

Low tone, weakness – preemies or conditions

Excessive jaw movements

ABNORMAL TONGUE MOVEMENTS

Strong protrusion – treat tongue

Treat underlying problems first– facial weakness/hypotonia, excessive jaw movement

External support – cheeks/lips and jaw support, too.

CHEEKS

Hypotonia/weakness, diminished fat pads

Poor stability leads to poor lip seal. Excessive jaw excursion may result

Increase facial tone

Cheek/jaw support

POOR INITIATION OF SUCKING

Crying, fussing, ‘tuning out’ – baby hungry and will become increasingly frustrated

May root excessively and unable to inhibit – turns head wildly from side-to-side

Extreme mouth opening and unable to close

Tongue protrusion/lapping pattern may be attempt as sucking

Hypersensitive response or poorly developed sucking patttern

Poor state/organizational abilities – overly hungry

POOR INITIATION

Treat underlying problems – if poor state/organization treat those underlying conditions

Preparatory handling

Stabilize front of head with jaw control as needed

Place nipple firmly at midline, cheek support as needed –for central reference point

Assist with mouth closure – firm jaw control to assist with closure, grading of mouth open, vibration to relax tension and assist with closure

Facilitate appropriate tongue movement

COORDINATION OF SSB

Prolonged sucking – feeding induced apnea

Having difficulty ‘pacing’ SS and B

Strong, rapid sucking with difficulty initiating breathing even when nipple removed

More common in preemies

External pacing

Be sure baby can initiate breathing

May have better regulation later in feeding

Decrease rate of flow – thicker liquid, slower flow – to allow time to organize

COORDINATION OF SSB

Short sucking bursts

1-3 sucks in a burst before pausing for multiple breaths

Pauses too frequent/long compared to sucking bursts

May be adaptive response

VFSS

Look at respiratory status

Endurance

COORDINATION OF SSB

Uneven pattern with duration of bursts/pauses varying considerably

May be uneven pattern of breathing and swallowing within the sucking burst.

Frequent choking/coughing noted

General neurological disorganization, respiratory problem, nipple flow problem

Assist with external organization

Understand respiratory status

Pace, reduce flow rate, bolus size

ENDURANCE AND RESPIRATORY COMPROMISE

Need to increase ventilation and cardiac output to match ‘work’ of feeding

Reduced intake, poor weight gain

Generally has normal OM control and SSB

Initially feeds well but stops early in feeding

Regulate liquid flow – faster at beginning to get more in, softer nipple, slightly larger hole. Monitor carefully!!

Manipulate feeding schedule – limit feeding time, time between feedings, demand schedule

Nutritional supplements, caloric density


Realistic expectations to cope with frustration

Structural abnormalities or respiratory disease = increase WOB

Much of available energy is used in cardiorespiratory system with little reserve for additional activity (i.e., feeding)

Increase WOB may lead to GER

Treatment for endurance should be considered

Reduce expectations for feeding

Small volume feedings


Structural abnormalities or respiratory disease = increase WOB

Much of available energy is used in cardiorespiratory system with little reserve for additional activity (i.e., feeding)

Increase WOB may lead to GER

Treatment for endurance should be considered

Reduce expectations for feeding

Small volume feedings; pacing

Stopping or postponing oral feeding

Supplemental O2, nebulizers

VENTILATION VERSUS PERFUSION

Ventilation – amount of air in and out of lungs and alveoli

Perfusion – ability of alveoli to exchange gas

Supplemental O2 is not helpful in all respiratory problems – if perfusion is poor, increasing O2 amount will not improve saturation in blood

May still be helpful with feeding since ventilation-perfusion ratio may change with increased work

Need oximetry

INCREASED NUTRITIONAL REQUIREMENTS: ADDITIONAL CALORIES

Skill in balancing medical and nutritional needs with parents’ skills and expectations

Frequently an issue with respiratory/endurance problems

OM skills generally intact so leads to optimism and enthusiastic pursuit of oral feeding

Perception of failure on the part of the infant or parent if goals not readily achieved

May need to change the way in which progress is measured

… Primary goal

INCREASED NUTRITIONAL REQUIREMENTS: ADDITIONAL CALORIES

May need to change the way in which progress is measured

… Primary goal should be infant’s overall growth

… Oral feeding often comes at a high price

… Supplemental nutrition should be viewed as support rather than last resort or failure

… Provides a built-in nutritional system during setbacks

… Focus on quality of oral control and parent-child interaction rather than calories

… Small volume/partial oral to build motoric and sensory foundations, hunger/satiation

ORAL-TACTILE HYPERSENSITIVITY

Responses are exaggerated out of proportion to stimulus (e.g., placing bottle or toy in mouth)

At the extreme end of hypersensitive responses

Easily elicited, stronger, more negative and often include a behavioral response

May cry, grimace, wiggle, arch away, keep mouth closed. If feeder persists may begin to gag and may vomit.

MULTIFACTORIAL CAUSE

Immaturity and illness – immature CNS, at the mercy of physiologic status, poor regulatory filtering mechanisms, becomes a pattern

Delayed introduction of oral feeding – critical period for acquisition of oral feeding skills may be missed (Illingworth & Lister)

Unpleasant oral-tactile experiences – negative or traumatic oral-facial experiences during the course of medical treatment

TREATMENT

Adaptive, well-modulated responses is the goal.

Reduce aversive stimuli – look at care routines

Grade oral/tactile stimuli – start in a range where the child is comfortable and slowly build up to a point where it is not tolerated and then step back slightly. “Dance” on the edge of the infant’s tolerance.

… May need to start distal and move proximal

… May need to move from smooth to soft to unusual to prickly, firm to light pressure, etc.

VIBRATION

Vibratory afferents are carried along different neural pathways than light touch and touch/pressure.

More integrating and less likely to stimulate an aversive response.

Can be effective even with preemies

Hold vibrator against finger, nipple, pacifier. Use an electric toothbrush.

ORAL EXPLORATION

Mouthing toys and hands is a crucial component in helping them tolerate increasing complexity and variety of oral sensations.

Variety – don’t let child get ‘stuck’ on only one thing.

Feeding specialist needs to reintroduce this stage of normal development in a way the baby can tolerate.

NON-ORAL FEEDING

Full non-oral feeding –

… Motor deficit

… Extreme tactile hypersensitivity/aversion

… State or arousal problems

… Medical conditions that preclude oral feeding

… Any combination of these

Existing OM skills should be maintained for future oral feeding and speech

Prevent oral aversion and hypersensitivity due to lack of oral input

Facilitate oral hygiene

NON-ORAL WITH TX ORAL FEEDS

Primarily non-oral

Feeding-related functions show adequate competence to allow small amount of safe oral feeding

To improve OM skills and move toward larger volumes as able.

Safe for oral but cannot take full oral

Allowed to feed as much as possible within certain parameters (length, frequency) with balance non-oral

NON-ORAL PLUS ORAL

Limited nippling at each feeding using good techniques and within physiologic parameters.

Amount not finished is given though tube

Use only with indwelling NGT or GT

Often used with preemies

Alternate nipple and tube feedings

Should be close to taking full volume

Good for those with limited endurance

NON-ORAL PLUS ORAL

Daytime oral and nighttime tube

TRANSITION FROM TUBE TO ORAL

Begin the process of transitioning to oral feeding at the point when non-oral feeding begins

Comprehensive and aggressive oral therapy program

… Normal OM skills

… Expected short-term use (6-12 months)

Primary objectives

… Minimize negative or aversive oral stimulation

… Promote pleasurable experiences and oral exploration

… Maintain/build OM skills and interest

… Associate oral activity with satisfaction of hunger

… Maintain whatever degree of oral intake that is safe

… When possible, expand rather than introduce

TRANSITION

Consistency, whatever program is established, is essential

Assess child and parents’ readiness

Often lengthy and difficult; it’s a process

… “He will eat when he’s hungry” does not apply

… Set goals that reflect steps rather than final outcome

Establishing level and quality of OM skills

Determine swallowing ability

What’s the original medical condition?

What’s the current status?

LETTING GO

Degree of OM impairment

Lack of change/improvement in medical status

Move away from oral goal in a way that supports the child and family

Quality of life

… ‘Recreational’ oral feeding

… Tolerates oral stimulation for ongoing hygiene to face, mouth, teeth, gums

DESENSITIZATION HIERARCHY

From 18 months and older

No obvious OM deficits

May have oral sensory problems due to sensory deprivation

Tolerating –

… Be in same room

… Looking at food

Interacting –

… Uses utensils in play, preparation


Smelling

… Tolerates odor of food

Touching

… Tolerates on fingers, hand, upper body, chin/cheek, nose, lips, teeth and tongue

Tasting

… Licks lips or tongue

… Bites and spits out

… Bites and holds in mouth before spitting out

… Chews and partially swallows

… Chews/swallows with drink

… Chews/swallows independently


Eating

Gradual changes that lead the child to functional eating without any specific intervention by others except expected monitoring for age

Individual variation as needed

… Collaboration with MD, RD, daycare, school or other therapists, with caregivers and child as primary team members!

… Consistent approach and encouragement/feedback

MEALTIME ENVIRONMENTS

Home, daycare, school, restaurant

… Modify environment as best you can

… Placemats, utensils, cups, bowls

… Proud plates, brag books

Adaptive seating

… Lightweight, washable, easy to use

… Fits under table to allow child to be included in mealtime

ORAL CONTROL – FROM SIDE OR BEHIND

First do positioning for best posture

Middle finger

… Behind chin on belly of tongue

… Inhibits jaw opening, helps closing, indirectly inhibits tongue protrusion

Index finger

… Between lower lip and chin

… Facilitates graded jaw opening, helps control head

Thumb

… Under chin, provides jaw stability only

ORAL CONTROL – FROM FRONT

Helps maintain eye contact

Requires more control from the child

Index or middle finger

… Under chin

… Provides jaw stabilization

Thumb

… On chin

… Facilitates graded jaw opening

TOLERATING FACE WASHING

Preparation for mealtime/snack activity and at end of meal/snack

Provide postural support and stability

Provide oral control as needed

Use firm, deep pats moving distal to proximal

… Cheek bones to lips, one side then the other, upper lip stretching downward, chin moving upward

Use different textured cloths

Use rhythm/singsong

SPOON FEEDING

Wash your hands and help child wash theirs


Begin with jaw closed

Spoon approaches from low to midline

Graded jaw opening – support as needed

Put spoon straight in – about half way

Press down and flat on tongue, hold to allow tongue to quiet and lips to close.

Take spoon straight out

Let upper lip learn to be active so don’t scrape against the lip

SPOON FEEDING

Clamping – provide extra flexion and wait for child to relax

Sensitivity – face washing and tooth brushing

Lip retraction – positioning toward midline

Tongue thrust before swallow – better head/neck control and oral control

No swallow – chin tuck/neck elongation, reload spoon and come towards them

CHEWING



Provide oral control

Begin with jaw closed

Food approaches from midline and low or level with mouth. Use food that is easy to handle

Graded jaw opening while maintaining flexion

Place food on chewing surface of teeth at side

Facilitate graded jaw closure

Maintain oral control; watch head and trunk

Don’t facilitate chewing motion – wait with continuous oral control

CHEWING

Tone in cheeks – use finger to stretch and release cheeks before starting

Poor lip closure – face wipe to stretch upper lip down, lower lip up. Push jaw up.

Exaggerated jaw movement – use oral control to grade jaw

CUP DRINKING

In typically developing children, spoon feeding builds to cup drinking



Provide oral control

Thicker liquids are easier to control in the beginning

Begin with jaw/lip closure

Approach at midline or slightly below level of the mouth

Place cup between lips – not between teeth

CUP DRINKING

Rest rim on but do not push down on lower lip

Tilt cup until it touches upper lip and wait

Goal is active downward motion of upper lip to draw in liquid

Don’t remove cup unless child pulls away – watch child’s signals

Maintain oral control

CUP DRINKING

Bite reflex – move out so it doesn’t happen

Gulping – prevent with slight chin tuck/neck elongation so the kid is looking down in the cup

Use thicker liquids, cut out cup, clear cup, let child help “hold” the cup

STRAW

Prerequisites: nasal breathing, lip seal with active lip function, light jaw closure, cheek and tongue movement to build up negative pressure

Wash, provide posture support and stability, provide oral control

Dip straw into liquid and place finger over hole on top

Place straw between lips, let a drop of liquid out and wait for active suck

Gradually require more suction by keeping finger over hole

Short, wide and small diameter straws

Use juice box

BOTTLE FEEDING

Need NNS to serve as a link that will facilitate transition to NS

Wash hands, provide posture support and stability

Provide oral control from the front – tongue control with middle finger, thumb and index finger on cheek to provide movement forward to facilitate sucking

Bottle approach from midline or below

Facilitate graded jaw opening

Pressure on tongue with nipple to stimulate suck

Rock or shake nipple may help if has intermittent suck

SELF-FEEDING

Wash, provide posture support and stability

Provide oral control if it has not been discontinued prior to this stage

Begin with finger foods to eliminate use of utensils

Hand-over-hand or child holding on to your fingers as you hold the food or spoon

Food or spoon at midline on table. Gather food on spoon.

Jaw is closed.

Food or spoon at midline.

SELF FEEDING

Spoon straight in, maybe pressing down on tongue for stability/organization

Spoon straight out, maybe pausing to let lips and jaw close

May need slight chin tuck/neck elongation to prevent biting on spoon

Spoon back to plate/bowl

Finger foods follow the same pattern but are presented laterally to facilitate chewing

QUALITIES OF UTENSILS

Spoons –

… size of bowl

… depth of bowl

… Size and weight of handle

Cups –

… size

… height/width

… cut out cup – see liquid, to prevent hyperextension

… Cup lip

… Flexibility

… Handles or no handles

QUALITIES OF UTENSILS

Finger foods

… Shape

… Texture

… Way to make it graspable

TREATMENT IDEAS

You set the stage – playful, fun, positive and calm

Activities with no food

… Touch/pressure to hands/feet (weight bearing, holding, deep pressure)

… Massage and vibration – Begin distal and move proximal

… Play with cups, utensils, dolls, tooth brushes, etc.

… Rhythm, bouncing, patting, stroking

… Sensory – lentils, corn meal, rice, play doh, damp sand, damp sponge, finger paints

TREATMENT IDEAS

Food activities – play – explore, measure, pour, art, put food on toy, put toy in mouth, drive food in cars, peanut butter play doh, etc.

Help prepare food – buy it, stir, grind, pass it, feed you, join the family at meal times, wash dishes

Many short work periods better than one long one

Once a week with family follow through

Carryover to home

TOOTHBRUSHING

Documents

SPHSC 543 MARCH 5, 2010 Questions?. TREATMENT Assessment will have identified if there is a problem and what the problem is. Any treatment plan