Activity-Focused and Collaborative Early Intervention

Rifton Rapport interviews Toby Long, PT, PhD, FAPTA

Toby Long, PT, PhD, FAPTA is Associate Professor in the Department of Pediatrics at Georgetown University, and the Director of Training and the Division of Physical Therapy at the Center for Child and Human Development.
Her work focuses on the evaluation and assessment of young children and service delivery to children with disabilities as well as training professionals.

RR: Toby Long, congratulations on becoming a Catherine Worthingham Fellow at the APTA Conference, June 2009. It is a privilege for Rifton Rapport to learn from you and share with our readers. What do you view as the most important outcome of therapy intervention?

Toby: Our ultimate outcome for the children and their families is that each child is able to participate in society throughout their life; to become a contributing member to society. The International Classification of Functioning [see ICF] promotes this: they discuss participation as an important outcome that we should all be directing our efforts toward. In order for that to happen, from early on, we have to create opportunities where children are participating in life. Our therapy should be directed to help children develop the skills and/or strategies that allow this, or to help our communities to build environments and systems that do facilitate this, to not create barriers, preventing participation.

RR: So this explains the increasing emphasis on "the natural environment." Could you talk about that?

Toby: The natural environment affords the opportunity to participate. This includes a whole host of places and activities that kids participate in. In early intervention you have a whole host of opportunities! We are not only talking about places at home or at child care, which oftentimes people think of as natural environments.

Rather than natural environments, I like to use the term 'activities and routines'. What activities and routines do very young children do with their family on a regular basis? They will always eat, they will always sleep, and they will probably go to the grocery store with their family. Activities and routines are individualized to the family. Knowing those activities and routines helps us to embed our therapeutic strategies into activities that families find important.

For example, for a toddler to go to the grocery store with the parent, the child has to either sit in the grocery cart, or perhaps push around a little cart that they have for kids at the store. So if a child has difficulty sitting in the cart because they have poor trunk stability, providing opportunities within that grocery cart to practice better trunk posturing would reinforce that skill, and give opportunity to practice that skill within that natural environment, right when that skill has to be done.

RR: How does the therapist incorporate this into their practice?

Toby: Actually, the therapist needs to think of it in the opposite way: How can they incorporate their practice into this approach?

This requires the creativity of the therapist. They want to promote trunk and postural control. Where does the child need it? Where does the family want the child to demonstrate this? Then to creatively think – how can I provide ideas or strategies that promote trunk control when and where trunk control is needed?

This requires that the therapists have in-depth conversations with the family about what they do, when they do it, why they do it, and how important it is, in order to prioritize. The therapist’s role is coaching, teaching, supporting the family, and in this way providing loads of opportunities for practice.

RR: So this is very different from the traditional developmental approach.

Toby: Yes, I think this requires a much smarter therapist. It requires a team approach and really thoughtful conversations.

Sometimes therapists say "Well, if I’m not doing something, putting my hands on the child, I’m not doing therapy." There actually isn’t much research evidence to show that bringing your child with a significant disability to the therapist once or twice a week for half an hour is going to do very much. But we do know that kids learn when given practice. And you need that practice in a variety of opportunities in order to generalize skills.

Certainly there are children who will learn the developmental motor milestones in the traditional sequence—maybe children born prematurely or those with mild developmental delays—children who are not going to have a significant disability. Providing them with opportunities where they are taught to do the various milestones may be appropriate. However, many times therapists see children with a known disability such as cerebral palsy, and this child will not follow a traditional developmental sequence. So to use that as your basis to formulate goals or objectives is probably going to make accomplishing the goals very difficult for the child and may be very frustrating for you as the therapist.

But with this collaborative, activity-focused approach, you’re using all the knowledge of a professional in order to solve the problem. With current motor learning principles, we want to both generalize and practice skills.

In reality, we really want to see children participate in whatever activity they want to, or are expected to do. Our role is to help them get there.

RR: This is very exciting because it means that the child will have more practice opportunity for skill building. Do you see assistive technology come into this picture?

Toby: Absolutely. I think assistive technology is playing a much bigger part in much younger children’s lives. Traditionally, assistive technology has been introduced to children when team members have determined that the child is not going to learn certain things. "Now that the child is 8 or 9, and is not going to learn to walk, we may start thinking about a wheelchair or another type of mobility device." More recently, however, people are beginning to think "This little guy is going to have a hard time moving around. Let’s give this 18-month-old a mobility device to get him moving around the environment." Then they can explore their environment actively, - while we are working on independent mobility - rather than being passively carried from place to place. It’s about giving them that ability to move around their environment on their own.

We’ve known for many years that active exploration of their environment is very important for cognitive development in small children. Research is showing that, when given a simple mobility device, young babies develop better cognitive skills than those who are not able to explore their environment on their own and are passively moved around or have their environment brought to them. So I think that independent mobility using assistive technology is extremely important.

RR: Does assistive technology promote, or will it interfere with, the child’s development of a skill?

Toby: Providing a young child with assistive technology is not saying that you’re not going to work on a skill. Think about this in terms of communication devices. We want to provide ways for kids to communicate on their own as early as possible, and not wait until "they’re not going to learn to speak." There is no evidence to indicate that providing assistive technology for communication or for mobility prevents the acquisition of either speech communication or independent mobility for a child who develops those skills. In fact, the assistive technology may promote communication or mobility, because it reinforces it. If a young child who cannot speak has a communication system, somebody is going to communicate with them and reinforce their reciprocal social interaction. This reinforces their desire to communicate, because now they have a social network. If the only time that they are able to communicate with somebody is when they go to the speech therapist, they may not be as motivated to make that communicative attempt.

RR: Do you see physical, occupational, and speech therapy clinicians who are working in pediatrics today, recognizing and practicing these evidence-based interventions?

Toby: More and more we all recognize the importance of this. Newer therapists are coming out of their training with more realization of and appreciation for these concepts of motor learning and team collaboration for service delivery. Unfortunately, they don’t necessarily see it practiced in the field so it isn’t always reinforced.

There are challenges. We’re now talking about being flexible, where therapists don’t necessarily need to see the child twice a week for the rest of their life. Maybe they need to see the child every single day for 3 weeks, and then pull back and six months later determine if the child needs to have therapy again. That kind of flexibility is very difficult from our reimbursement system, which is based on the traditional medical model of service provision.

It’s also difficult from a scheduling standpoint. School-based therapists are required to indicate on the Individualized Education Program how much therapy they are going to provide to the child. So issues of duration, intensity and maintaining a schedule can be very difficult. Administrators want to know exactly what you’re doing, when you’re doing it, who you’re doing it with. So there’s got to be a way of documenting that.

The Section on Pediatrics of the APTA is working very hard to help therapists think creatively. How they can provide their service, get reimbursed for their service, and continue to provide their service in a way that is much more contemporary.

RR: Would you have any parting thoughts to leave with our readers, regarding this contemporary therapy service provision that is outcome-driven, activity-focused, and collaborative?

Toby: We have to be consistent in our approach so that families don’t get mixed messages. Whether you’re a school-based therapist who may not be working in early intervention, or if you are an early interventionist and you’re not working in the school system, or even our hospital-based therapists—we all have a role in this. And start early!

RR: Thank you very much for taking the time to speak with me today.