15 Kerry Wallace Clinical Director, Polkaspot Early Intervention Centre, Cape Town, South Africa Trustee, SPOTlight Trust SA, Cape Town, South Africa Department of Occupational Therapy, School of Health Sciences, University of KwaZulu-Natal, Durban, South Africa Providing a framework for the identification and early intervention for young children includes a broader knowledge base to address meaningful occupational therapy for children who are at risk for developmental and mental health disorders. The occupational therapist’s knowledge of himself/herself and the continuous utilisation of clinical reasoning are of vital importance and will be emphasised throughout. During infancy and early childhood, not only is the brain growing quickly, but it is forming the relationships between its different components in the formation of the synaptic connections (Siegel 1999). In this age group, although the infant or young child is presenting with red flags that result in a referral to an occupational therapist, not only the child but also their whole family needs to be included in the assessment and intervention process. This approach represents a shift away from the medical model where the occupational therapist interacts directly with the child as a playmate, and the dyadic relationship serves as a model for future relationships. In a family-centred model, the occupational therapist’s role is that of a consultant and coach and models adaptive interactions. The occupational therapist coaches the significant adults, the child’s parents and teachers in natural environments, facilitating adaptive behaviour. Therefore, intervention may not only occur in a therapy centre but also in the child’s home, on the playground, in the classroom, in the shopping centre or at the beach, wherever the child faces difficulties due to his/her specific challenges. A paradigm shift has occurred in the last 10 years from a behavioural to a dynamic developmental systems model, and integrated interdisciplinary interventions are needed. Occupational therapists need to treat relationships and not just the child – the caregivers are the vehicle for emotional and intellectual development. Interventions need to be tailored taking into consideration individual differences in the child and the family in their culture and the environments in which the child lives, learns and plays. The beauty of the paradigm shift is that instead of the occupational therapist only working directly with the child, he/she helps the parents to use opportunities in everyday activities that would be based on age-appropriate occupational performance goals and helps the family to use real-life culturally appropriate situations to build their child’s independence. Every child has an inner world and so does each parent in relation to their child, which needs to be respected. This is the starting point for any intervention plan. Most important is the concept that affect is central to how children relate, learn and understand. Therefore, emotions drive early cognitive development. Competencies come from experience, not training. The following stage of development builds on what has already developed. The intrinsic motivation by the family to participate in the therapeutic process is the critical factor in effecting change. By capitalising on neuroplasticity (changes in neural pathways and synapses) (Ratey 2002), the stress and frustration of underachievement in a child can be avoided. A comprehensive approach requires a multidimensional and multidisciplinary focus. To minimise the impact of infant and early childhood disorders, a comprehensive evaluation followed by a clinical formulation and recommendations for a comprehensive intervention programme must be included. In the 21st century, there has been an explosion of new information in this field supporting the need for evidence-based practice. There are many treatment models for children with autism and other special needs, yet every child is unique and no one approach is right for all growing children. Often, parents making important choices for their children are overwhelmed and confused by the options they are given. Others have to utilise limited resources in their area where practitioners are trained in only one model rather than across several disciplines and models. New information on genetic and environmental influences is relevant. Research shows infants with a regulatory disorder, premature infants or those with persistent attention deficits and sensory processing disorders are at risk for mental health disorders (Bayrami et al. 2007). Schoolchildren diagnosed with moderate to severe regulatory disorders in infancy are at high risk for perceptual, language, sensory integrative and emotional/behavioural difficulties in the preschool years. Through early detection of regulatory disorders, it may be possible to prevent more serious delays in motor, language and cognitive development and parent–child relation problems (DeGangi et al. 2000). The incidence of autism in the population has been increasing exponentially, from 1:150 in 2007 to 1:88 in 2012. It is 1:54 in boys (Autism Speaks 2012). A predisposition to developing an autism spectrum disorder is polygenetic. Traits run in families and although 10–20 interacting genes have been identified, no genetic disease has ever increased at this rate. In 25% of cases, there are family members who have problems in social engagement or have language delays. Electroencephalograph (EEG) and neuroimaging studies show consistent pictures of overgrowth in some areas of the brain and poor synaptic development in others (Kotoury et al. 2009; Duffy & Als 2012). Epigenetic factors are proving to be highly significant in understanding challenging behaviours. Some premature infants are at risk for a variety of reasons, such as those who show an especially high susceptibility to viral infections or have a severe vaccination response and those extremely sensitive to allergens due to their constitutional fragility. Environmental factors, especially the prenatal environment, are also under the microscope (Solomon et al. 2007). Methodological advances are providing new insights and much needed evidence for long-held occupational therapy treatment assumptions, due to the fact that most of the connections in the brain develop postnatally. A retrospective video review showed that children of four months who could not conduct multiple activities simultaneously, that is, make eye contact, vocalise and kick their legs, had difficulty later with social interactions and demonstrated early signs of poor affective connections (Bayrami et al. 2007). The underlying reason for their developmental delays is postulated to be associated with poor brain interconnectivity. The most complex skills a child will need to acquire are language and social–emotional development, which require the most inter-neural connectivity. Encouraging research shows that 50–60% of children with autism spectrum disorder can make changes in their neuronal structure through neuroplasticity. However, there is a need to open opportunities for multiple diagnoses and early intervention (Bayrami et al. 2007). Intensive early intervention has the potential to create change in the structure and function of the brain and preventing or minimising the manifestation of pervasive developmental disorders. Intensive early intervention programmes treat underlying issues, making speech and language therapy and occupational therapy important. Both focus on underlying sensorimotor development and have stood the test of time (Greenspan & Wieder 2006). Intensive relationship child-centred developmental approaches, including well-known approaches such as Developmental, Individual Differences, Relationship-Based Floortime (DIR®/Floortime) (Greenspan & Wieder 1997), enable the child to engage, interact and then form relationships. Through interactions, the child develops a sense of self, joint attention, symbolic play and thinking-based learning (Kasari et al. 2012). The PLAY Project programme uses this approach to train parents and teaches them how to play with their children (Solomon et al. 2007). Research shows it is possible to repair social–emotional deficits caused by either genetic or environmental factors. Play is the context for the development of communication and higher level thinking in young children. Experiences build brain architecture (Ratey 2002). An understanding of the normal functional emotional developmental stages, seen in typically developing children, enables occupational therapists to identify how to intervene and support families when there are social–emotional and or learning challenges (Centre on the Developing Child at Harvard University 2011). Not only genetically vulnerable children but also those exposed to emotional trauma or deprivation, for example, children who have been placed in adoption homes for a long time before adoption or multiple foster homes who do not have the benefit of a consistent, predictable adult co-regulator, are at risk. Maternal postnatal depression can also affect the mother–infant attunement, and even when there is no pathology, infants and their mothers who have either very different or similar personality or sensory profiles can affect the goodness of fit in the maternal–infant relationship and can cause emotional dyssynchrony. Occupational therapists are well placed as early intervention professionals to assist caregivers and parents of children who are presenting with difficult behaviour. Understanding the reasons behind the behaviour enables the occupational therapist to provide parental support and strategies to address early signs of mental health issues. Behavioural models prevail and some children benefit from these approaches. Applied Behaviour Analysis (ABA) (previously known as behaviour modification), which demands 1:1 drills for skills with rewards, has the most evidence, and children learn skills they have been taught. However, this does not address the underlying problems, as the approach is symptom based. Thus, generalisation of the behaviour to different circumstances and nuances does not apply. There is an abundance of information that is shaping new ideas about developmental disorders. The Early Start Denver Model (ESDM) is showing promise in training parents in behavioural strategies (Rogers & Dawson 2009) (Figure 15.1). Figure 15.1 Diagram of a multiaxial approach. Source: Reprinted with permission of the ICDL-DMIC 2005. © ICDL-DMIC. The first step is the identification of a primary diagnosis. This is based on whether the presenting problem is evaluated to be either primarily interactive related to the caregiver–child relationship (100); physiological (200), neurodevelopmental (300) or primarily language origins (400); or a learning disorder (500). During the initial assessment, the therapeutic team makes a preliminary diagnosis in order to identify the full range of interventions necessary for the child and family. A multiaxial evaluation in conjunction with caregivers is a first step towards formulating a tailor-made treatment plan to address the child’s developing functional capacities. When a known trauma or stressor has occurred, a primary diagnosis of traumatic stress disorder is made. In interactive disorders, the primary difficulty stems from the infant–caregiver or child–caregiver relationship and related family and environmental patterns, for example, anxiety related to difficulties with developmental tasks or transitions, performance anxiety or anxiety related to the child–caregiver interaction in the case of separation anxiety or reactive attachment disorder. Differences in the child’s constitutional and maturational variations, in terms of sensory over- or under-reactivity; visuospatial, auditory and language processing; or motor planning and sequencing difficulties, are the primary contributors to the child’s challenges. In addition, sensorimotor processing challenges often manifest in interactive behaviour disorders; therefore, clinical reasoning on the part of the therapist is required in order to ascertain whether the primary issue is physiological or relational due to a misfit. Children diagnosed with neurodevelopmental disorders often have associated regulatory sensory processing and interactive communication difficulties, for example, Down’s syndrome, autism spectrum disorder, fragile X and Williams syndrome. When challenges in communication in the context of a developmental framework that considers all components of language (gestures, motor, sensory, social) are primary and are not part of a major disorder, for example, autism spectrum disorder, a specific speech and language diagnosis is applicable. Early identification of the pathways associated with later learning differences and challenges at school age enables the clinician to optimise early interventions that may resolve or ameliorate these challenges later. These include difficulties with reading, comprehension, mathematics and written expression as well as organisational capacities requiring executive functioning. In order to get a sense of the prognosis of a young child, the functional emotional classification of children at risk for social–emotional disorders is helpful: These children have intermittent capacities for attending, relating, reciprocal interacting with support and shared problem-solving. They are typically highly reactive to affective or social situations, even a raised voice results in problems setting limits. They need predictability and structure, demonstrating resistance to change in routine and challenges. Extremes in moods and limited affective modulation may result in a child who cries easily. They show rapid progress in a comprehensive programme that tailors meaningful emotional interactions to their unique motor and sensory processing profile. These children have capacities for attention, relating and back-and-forth reciprocal interaction, with fleeting capacities for shared problem-solving. They are dependent on co-regulation by an adult caregiver or routines and have a limited range of adaptable behaviour. They use limited self-soothing strategies, for example, flapping of hands. They engage in stereotypic play and struggle to move on to symbolic play, and there is poor social problem-solving; however, they make steady progress. These children are hyper-alert and hyperactive, so they are unable to organise their attentional responses. Difficulties exist with simultaneous processing, and stimuli limit exploration of the environment. Their persistent, pervasive disorders of state regulation (arousal and emotional state) result in fleeting capacities for attention and engagement, and with lots of support, they have the potential for a few back-and-forth reciprocal interactions. Often they have little capacity for repeating words or using ideas, although they may repeat a few words in a memory based rather than a meaningful manner. Children with this pattern make slow steady progress, especially in the basics of relating with warmth and learning to engage in longer sequences of reciprocal interaction. The very poor organisation of physiological and sensory systems with multiple regressions is associated with neurological challenges, for example, seizures or marked hypotonia. These children make very slow progress, and if the triggers for their regressive tendencies are identified, progress can be enhanced (ICDL-DMIC 2005). For a detailed account on Axis III, see Table 15.1. Table 15.1 Axis III: sensory regulatory capacities. There are a number of physiological–maturational differences in the way that infants and young children register, respond to and understand sensory experiences and plan actions. These patterns range from those seen in typically developing children to a range of dysfunctional responses. Disorders occur when the responses are sufficiently severe to interfere with age-expected emotional, social, cognitive or learning capacities. In each category, the clinician can indicate whether, for example, sensory hypersensitivity falls under the following criteria: For the purposes of the occupational therapy evaluation, language capacities focus on functional communication. This starts with the capacity to read the caregiver’s gestures and facial expressions and then the ability to use facial expression and gestures to communicate intent. The use of vocalisations precedes the emergence of verbal communication, and occupational therapists need to bear in mind the effect of auditory processing on receptive language and praxis on verbal command, on the ability to follow instructions and on oral dyspraxia on expressive language. Vision plays an important role in the development of the sense of self. This develops through integrating visual information with somatosensory feedback and information from the vestibular system resulting in the development of a body schema. Body awareness in space, understanding relationships between objects to self and others, conservation of space and object permanency develop during the first year of life. During the second year, visual logical reasoning for problem-solving and representational thought through play with objects emerge and ultimately lead to symbol formation. In the third year, the connection of visual-motor pathways is evidenced in the emergence of representation of visual-spatial maps in drawing and ultimately abstract thinking and visualising. A child with visual-spatial challenges needs to be fully investigated by an occupational therapist and/or developmental optometrist. The overall functioning of the caregiver identifies the degree to which he/she is able to support the child’s negotiation of each developmental level. The occupational therapist needs to identify issues that may interfere and can then supply support information. The caregiver can also be referred to a mental health professional for individual counselling. Psychosocial stress from the environment and personal stress can be the cause or contribute towards or exacerbate primary symptoms. Wherever possible, the alleviation of stress on the family unit is critical. Positive outcomes will be seen in those children who have relationships to support them. They are more resilient, better problem solvers and exhibit less maladaptive behaviour. Rigorous therapy regimes that sap the family resources and emotional capacities need to be viewed with caution. This population of children is medically vulnerable so they need to be closely monitored by a developmental paediatrician, so that any issues that arise can be addressed timeously. Allergies and respiratory, dermatological and gastrointestinal symptoms need thorough investigation because medical factors impact on the children’s emotional state and their capacity to overcome developmental challenges (Robinson 2011). The Interdisciplinary Council for Developmental and Learning Disorders’ (ICDL) mission aims to improve identification, prevention and treatment of developmental and learning disorders. The organisation was founded by Dr. Stanley Greenspan (child psychiatrist) and Dr. Serena Wieder (psychologist) and Georgia DeGangi (occupational therapist). The ICDL hypothesises that symptoms among children with special needs come from the same basic core but with different variations. The concept of co-morbidity which creates the illusion that these are separate and distinct biomedical diseases is questioned, as in most instances there is no known specific genetic cause for each of these patterns. The theory of epigenetic phenomena, ‘nurture’ which turns specific genes on and off, for example, environmental factors, which operate when ‘nature’ has prepared the way, is supported. Genetic–biological differences are expressed through motor, sensory and affective processing differences. The emphasis is placed on the role of parents with genetically vulnerable children to change the children’s developmental trajectory and optimise their developmental potential (Greenspan & Wieder 2006). The role of the occupational therapist based on clinical reasoning skills is to coach the caregiver. However, due to the relationship and time spent with the child, it is the caregiver who needs to be the facilitator of developmental change. When investigating any form of anxiety, several perspectives need consideration. Firstly, is the anxiety primarily related to child–caregiver interactions? When a known stressor or trauma has occurred, a diagnosis of traumatic stress disorder takes precedence. Secondly, is the anxiety primarily related to anticipated developmental transitions or tasks the child is having difficulty mastering? Or thirdly, is the anxiety related to a regulatory sensory processing disorder? Hypersensitivity towards the environment leads to anxiety (Lane et al
Early Intervention for Young Children at Risk for Developmental Mental Health Disorders
Rationale for early intervention
Evidence-based practice
Etiological evidence
The neuroscience evidence
The neuropsychological evidence
The behavioural evidence
A multiaxial developmentally based classification for developmental and mental health disorders (Refer to Figure 15.1 above)
Axis I: Primary diagnosis
Interactive disorders (100)
Regulatory disorders of sensory processing (200)
Neurodevelopmental disorders (300)
Language disorders (400)
Learning challenges (500)
Axis II: Functional emotional developmental capacities
Type I
Type II
Type III
Type IV
Axis III: Regulatory-Sensory Processing Capacities
Sensory
Motor planning
Communication and play
Future
Type I
Hypersensitive to touch and sound
Fair motor planning
Spontaneous language
Rapid progress with solid academics in a mainstream school
Under-reactive to movement
Good imitative skills
Warm affect, healthy peer relationships
Type II
Under-reactive and self- absorbed
Weaker motor planning results in avoidant behaviour
Manages short sequences back and forth
Slower progress either in a remedial school or with a facilitator in an inclusion system. Independent living
Stronger visual memory
Use of short phrases
Learn to speak initially scripted language
Type III
Moderate to severe auditory and visual- spatial processing
More severe motor planning difficulties result in self-absorption and aimless wandering
Dyspraxia affects speech
Special education and assisted living
Learn to read words, sign and use Picture Exchange Communication System (PECS). Develop early levels of symbolic play
Type IV
Under-reactive to sensation
Very severe motor planning and low muscle tone affects speech
Fleeting intermittent engagement
Lifelong care with family or in a supportive environment. Overt neurological involvement
Severe visual-spatial and auditory processing
Problem solve to get what they want
Axis IV: Language capacities
Axis V: Visual-spatial capacities
Axis VI: Child–caregiver and family patterns
Axis VII: Stress
Axis VIII: Other medical and neurological diagnoses
A developmental hypothesis for manifestation of psychiatric disorders
Developmental pathway to anxiety
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Understanding Persons with Personality Disorders: Intervention in Occupational Therapy
Sensory Integration in Mental Health
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