czone.eastsussex.gov.uk · Web viewW sitting, bottom shuffling and in-toeing are not indications of...
Transcript of czone.eastsussex.gov.uk · Web viewW sitting, bottom shuffling and in-toeing are not indications of...
Version 1: August 2016
Review date: August 2018
East Sussex Children’s Integrated Therapy Service
ESCITS Referral Guidance
CONTRACT In Scope
REFERRALS ACCEPTED
CONTRACT Out of Scope
REFERRALS NOT ACCEPTED
Age Criteria:
Children and Young people 0-16 years
16-19 if in full time education in East Sussex
16-19 years if not in full time education
Moderate to severe global development delay Neurological conditions affecting development and
posture e.g. cerebral palsy, muscular dystrophy etc. Rehabilitation following multi-level surgery who are
known to CITS Acquired brain injury, for example post encephalitis/near
drowning NB this does not include intensive rehabilitation and children and young people should be ready for discharge to community therapy services.
Oncology Palliative care Syndromes affecting neurological development Developmental co-ordination disorder (DCD) – subject to
DCD pathway criteria Eating and drinking difficulties relating to neurological
developmental disorders. Respiratory conditions that require teaching of clearing
of secretions e.g. cystic fibrosis Orthotic provision for children on active CITS caseload ASD diagnostic pathway for all children referred whilst
still in primary education Language – subject to completion of specified
programmes in settings and schools Phonological disorder Developmental verbal dyspraxia Voice disorders Hearing impairment
Paediatric musculoskeletal conditions: All Children presenting with primary orthopaedic problems,
for exampleo Adolescent joint paino Post fracture rehabilitationo Sprained ankleo Osgood Schlatters; anterior knee pain, Perthes
diseaseo Idiopathic scoliosis/back paino Idiopathic toe walker with no underlying neurological
pathology, or post serial casting if not already known to CITS service and non-neurological in origin
These children should be referred to MSK services
Podiatry services for children:o Minor foot/gait anomalies for example flat feet, in-toeing
with no associated neurological delayo Shoe raises for children who are not on active CITS caseload
– these children should be referred to surgical appliances
Generalo A single diagnosis of hypermobility where there are no
Version 1: August 2016
Review date: August 2018
Scoping document
Cleft palate and non-cleft velo-pharyngeal insufficiency Severe language delay, if not in line with cognitive levels Dysfluency Selective Mutism Augmentative and alternative communication Juvenile idiopathic arthritis Talipes/Ponseti Hip dysplasia/Pavlik harness Severe hypermobility if condition is significantly
impacting on gross motor functional ability Torticollis Erb’s palsy Post orthopaedic surgery for children on CITS caseload
with pre-existing developmental or neurological condition
Chronic fatigue syndrome/Chronic regional pain syndrome – where children are under the primary care of CAMHS/primary mental Health Services
Severe sensory processing difficulties in children over 3 years, affecting function in at least 3 defined areas of self-care or activities of daily living. Please note this does not include attention in the classroom.
Serial casting post Bo-tox
associated functional difficultieso Weight management referralso Protective helmets for children with epilepsy who are not on
CITS active caseload – these helmets are ordered by the epilepsy specialist nurse
o Handwriting difficulties without additional functional difficulties
o CITS does not provide the following therapeutic approaches – ABA, Conductive education
Orthotic provisiono For non CITS caseload – see podiatry services and
helmets
ASD Diagnostic pathway for Children over 11 (NB these children should be referred to CAMHS)Paediatric In-patients Therapy provision to in-patients is not provided. Pathways will be in place to facilitate early hospital discharge. In-reach advice will be offered to support in-patient
management of children on active CITS caseload with complex physical disabilities
Therapy provision to individual babies on SCBU is not provided; but pathways to facilitate transfer of care to Community therapy services on discharge will be put in place.
There will be case by case discussions with Commissioners to agree bespoke funding packages for children requiring:
Intensive rehab post innovative out of area treatment (charity funding)
Intensive rehab following early discharge from head injury unit
Version 1: August 2016
Review date: August 2018
Global development delay
Syndromes affecting neurodevelopment
Cerebral palsyAcquired brain injury
PhysiotherapyHip dysplasia/ Pavlik harness
Erb’s palsyTorticollis
RespiratoryTalipes/ Ponseti
Juvenile idiopathic arthritisOrthotics
Speech and language therapy
VoiceSpeech sound delay/disorder
Language delay/ disorderFluency/ stammeringHearing impairment
Selective mutismCleft palate
Occupational therapy/ speech and language therapy
Eating and drinking disordersAutism spectrum disorderAugmentative/ alternative
communication
Occupational therapyVisual perceptual difficultiesActivities of daily living: self
careMinor and major adaptationsFunctional skills affected by
sensory difficulties
Physiotherapy/ occupational therapy
Developmental co-ordination disorder
HypermobilityEquipment
Version 1: August 2016
Review date: August 2018
East Sussex Children’s Integrated Therapy Service
This graphic describes the children we work with, both in terms of their diagnosis and needs.
It shows when the disciplines might work together. However two or more disciplines may not always be needed. Sometimes they may be involved with a child and family at different times depending on the child’s changing needs.
The emphasis of Occupational Therapy is enabling. This means helping children to overcome functional difficulties that affect daily life and may present at home or in the school environment.
Referrals are specified for children who present with significantly delayed motor development which impacts on their daily functioning. This includes children with an underlying neurological condition, motor-planning difficulties, global developmental delay, ASD (where skills are not in line with diagnosis), upper-limb dysfunction, palliative care and life-limiting conditions. There is an expectation that all school-age children access the Jump Ahead programme, designed to address fine/gross motor skill acquisition and Sensory Circuits (sensory-motor programme) at school before a referral is considered.
Postural management
Occupational Therapists work closely with Physiotherapists to identify appropriate seating systems or equipment to support 24 hour postural management of children with complex physical disabilities. Seating can range from low level postural support to complex, dynamic modular seating systems. Similarly, Occupational Therapists will work closely with their Physiotherapy colleagues in relation to prescription of sleep systems to ensure correct positioning at night-time.
Version 1: August 2016
Review date: August 2018
Occupational Therapy Guidance Details
Activities of daily living
Occupational Therapists are able to identify and work with children to identify the underlying difficulties preventing a child from being as independent as possible in areas of self-care. Interventions may be in the form of a programme, advice, direct intervention from an occupational therapist or Integrated Therapy Assistant under the guidance of the treating therapist or by adapting an activity to meet the needs of the child. Interventions may include the following:
Dressing, use of techniques such as backward chaining to support skill progression Eating and drinking, e.g. use of cutlery, dycem (non-slip mat), plate-guards and activities Access to suitable bathing/ toileting facilities
Equipment/ minor adaptations to support daily living
Occupational Therapists may provide equipment to facilitate independence either in the home or to access education. Interventions may include the following:
Access to bathing/ showering: bath-lifts, bath-boards, grab rails and shower-chairs Toileting - commode, toilet-frames, specialist modular toileting systems Manual-handling equipment e.g. mobile hoists, transfer-boards, slide sheets
Adaptations (0-18) over 18’s should be referred to Adult Social Care
For children with complex physical disabilities or challenging behaviours compromising their safety in the home, there may be a need to adapt the home/ and or school environment. Major adaptations are subject to criteria set out in the Disable Facilities Grant legislation and the budget is held by local councils. Occupational Therapists are responsible for assessing need under this legislation and making clinical recommendations regarding reasonable adaptations to meet a child’s needs. It is not always possible to provide a solution within the grant funding, in such cases the Occupational Therapist will work with the wider multi-agency team to support a family with exploring re-housing options.
Version 1: August 2016
Review date: August 2018
Motor co-ordination difficulties which severely affect functional daily living a referral will be considered where children have accessed the Jump Ahead programme or Sensory Circuit programme but there are still ongoing difficulties e.g.:
Sequencing movements Spatial awareness Body awareness Motor planning
Evidence is required where a child has been unable to progress and Jump Ahead should be completed a minimum of 3 times a week for 4 academic terms.
Visual perception
Visual motor integration impacts on handwriting and letter formation. Please note we do not deliver handwriting programmes but will assess and advise schools regarding implementation of appropriate programmes where applicable.
Sensory processing
There should be evidence of severe sensory processing difficulties in at least three defined areas of self-care or activities of daily living e.g. using cutlery, managing buttons, dressing, toileting difficulties, pencil grip or personal hygiene. Attention does not count as an activity for daily living. We are not commissioned to provide interventions for children with sensory processing difficulties under age of 3 unless they are under a specialist Tertiary Centre such as Evelina Children’s Hospital or Great Ormond Street Hospital for sensory processing difficulties.
Version 1: August 2016
Review date: August 2018
Neurological concerns or conditions affecting development please refer in for any of the following:
All children with a new diagnosis of Cerebral Palsy (CP) or showing signs of an evolving motor disorder. Children moving in to the area with an existing diagnosis of CP who have functional difficulties. Babies and children presenting with any of the following:
- Abnormal tone- Asymmetrical movement or unusual movement patterns. W sitting, bottom shuffling and in-toeing are not indications of an
abnormal movement pattern unless abnormal tone is present- Functional difficulty i.e. difficulty standing or walking and out of line with normal developmental parameters - Delayed milestones or poor quality of movement
Version 1: August 2016
Review date: August 2018
Physiotherapy Guidance Details
Acquired brain injury
CITS do not deliver intensive rehabilitation. The child should be ready for discharge to community therapy services
Neuromuscular conditions which involve a progressive loss of functional motor skills E.g. Charcot Marie Tooth, Spinal Muscular Atrophy, metabolic disease, muscular dystrophy)
Treatment and frequency will vary depending on the age and the stage of the child.
All children with a new diagnosis of neuromuscular disease Early Years children with a plateau of gross motor development for more than 6 months Children demonstrating a regression or loss of motor skills Post orthopaedic surgery related to their condition
Developmental concerns including moderate to severe global developmental delay and syndromes
Please see developmental table below. Developmental norms are taken from Mary Sheridan, Birth to Five Years. 4 th Edition.
Please note: Bottom shuffling is not an abnormal movement pattern. Many children who bottom shuffle instead of crawling to move around the floor start walking at a later age.
Activity Usual milestone Refer to Physiotherapy
Independent floor sitting 5 – 9 months 10 – 12 months
Independent rolling - 8 – 10 months (may need referral to physiotherapy earlier if there is a
Version 1: August 2016
Review date: August 2018
From front to back
From back to front
5 – 6 months
6 – 7 months
concern about head control)
Pulling to stand 7 – 12 months 13 – 16 months
Cruising around furniture 9 – 16 months 17 – 20 months
Independent walking 9 ½ – 17 ½ months (children who bottom shuffle are usually delayed in walking 17 – 28 months)
18 ½ months
Jumping 2 ½ - 3 years 4 years (a child who is not jumping at three is likely to have been known to the service previously for delayed walking)
Climbing stairs 3 years (up and down holding a hand or a rail, usually 2 feet per step)
4 years (a child who is struggling with stair climbing at three is likely to have been known to the service previously for delayed walking)
Developmental coordination disorder
Children with motor coordination difficulties would be seen either by an Occupational Therapist or Physiotherapist. Please see OT guidance on motor coordination difficulties for more information (page 6).
Toe walkers
The service would not normally accept referrals for toe walkers with no obvious neurological signs. Children should be referred if:
Version 1: August 2016
Review date: August 2018
There is asymmetry Not possible to achieve 90 degrees at the ankle and there are associated developmental concerns or altered muscle tone. Where there
are no associated concerns, or if the toe walking is intermittent then referral to musculo-skeletal physiotherapy service provided by East Sussex Healthcare Trust is more appropriate
Toe walking with unusual body posturing or movement
In-toeing
It is very common for young children’s feet to turn in when they walk. This is a common normal variant.
Referral to physiotherapy is only indicated if there is:
Significant asymmetry Pain Metatarsus adductus (Figure 1) where it is not possible to passively correct the
position of the forefoot to midline
Orthotics
This provision is only for children already on the CITS caseload. No physiotherapy intervention is indicated in children with flat feet or feet that turn out. If pain is present then a referral to podiatry services provided by East Sussex Healthcare Trust is advised.
Musculoskeletal problems
Version 1: August 2016
Review date: August 2018
Figure 1
Children presenting with musculoskeletal problems should be referred to the appropriate Musculoskeletal (MSK) Physiotherapy Service.
We do accept referrals for babies with musculoskeletal problems this could include the following:
Congenital foot abnormalities e.g. Talipes (club foot) Preferential head turning (Torticollis) Hip dysplasia (DDH) Shoulder dystocia with apparent neuromuscular signs (Erb’s Palsy)
Chronic fatigue syndrome and chronic regional pain syndrome
Children with chronic fatigue syndrome and chronic regional pain syndrome can only be referred to CITS physiotherapy where they are under the primary care of CAMHS. Physiotherapy can advise on graded exercise and pacing of activities.
Hypermobility
Only refer to CITS physiotherapy when the condition is significantly impacting on gross motor functional ability e.g. causing sleep disturbance on a regular basis or impacting on attendance at school.
Juvenile idiopathic arthritis
Referrals are accepted for children with functional difficulties at home or at school who require advice on long term management of their condition.
Version 1: August 2016
Review date: August 2018
Respiratory conditions
Referrals to CITS physiotherapy will be accepted for children who require teaching techniques to help clear secretions e.g. cystic fibrosis.
Please note that the flowcharts and development norms charts for comprehension, expression and speech sounds should no longer be used to accompany referrals for speech and language. Completion of the referral form should be sufficient, though further evidence e.g. Ages and Stages Questionnaire, Schedule of Growing Skills, Language Checkers and East Sussex Speech Language and Communication Monitoring Tool can all be submitted as further evidence for referral.
Dysfluency also called stammering or stuttering
Referrals considered from 27 months after the integrated health review
Many children experience non-fluency when they start to talk in phrases and sentences between 2-3 years. Usually this non-fluency subsides within 3-6 months. If there is no sign that the fluency is improving after this time we would advise a referral. In particular where the child is aware of their fluency difficulty we would advise immediate referral.
Selective MutismReferrals considered from 27 months after the integrated health review
Selective mutism is more than shyness alone; children who have selective mutism will talk freely in some situations, e.g. at home, but will have strict rules about where they talk and who they talk with. For example, they may stop talking at home if someone outside the immediate family unit joins them. The inability to speak interferes with children’s ability to function in that setting, and is not better explained by another
Version 1: August 2016
Review date: August 2018
Speech and Language Therapy Guidance Details
behavioural, mental or communication disorder. We would always advise referral where selective mutism is a concern; outcomes are much better with early intervention.
Eating and Drinking
Referrals considered from birth
Consider referral when you see the following:
Baby has difficulty establishing or maintaining a sucking action. Any coughing, choking, colour change or nasal regurgitation Baby is distressed when feeding or straight afterwards, they may also vomit a lot, draw legs up in pain, unable to suck on a teat, weight
loss, speak to G.P, then refer Child unable to chew a range of textures or manage family meals, may become distressed, cough, choke at mealtimes or vomit, weight
loss Eating and drinking difficulties as a result of degenerative condition It is important to consider that children may present with behavioural feeding difficulties such as gagging on specific textures, rigidity
around times of eating, aversive behaviours around temperature of foods, colour of foods, texture of food and smell of food. Referrals for children who only have behavioural difficulties in relation to eating and drinking would not usually be accepted.
If you are unsure about whether to refer, please contact the service for further telephone advice.
Speech sound delay/ disorder
Referrals considered from 3 years
Children with significant speech sound delay/ disorder aged between 2 and 3 years will usually present with a significant language delay and any referral would be accepted on this basis (see below). By the time a child reaches their third birthday they should be mostly intelligible to most adults although they will still have several speech immaturities. If a child is still very difficult to understand after the age of 3, a referral should be considered.
Language delay/ disorderVersion 1: August 2016
Review date: August 2018
Referrals considered from 27 months after the integrated health review
Referrals are not accepted under the age of 27 months unless the language delay is part of a severe global developmental delay or neuro-developmental disability. Where a child’s language or communication is out of line with their other development, a referral should be considered. Nursery settings may also submit the East Sussex Speech, Language and Communication Monitoring Tool to identify a significant communication difficulty.
Voice
Referrals considered from birth
Referrals for children with voice problems should always come through ENT or other specialist tertiary centre. If there are concerns about a child’s voice quality (e.g. hoarseness, voice loss etc.) this should be investigated via ENT services first.
Cleft palate
Referrals considered from birth
Children with cleft palate sometimes experience feeding or speech sound problems. They are usually referred to us by tertiary services but can be referred directly (please see under Speech sound delay/disorder and Eating and Drinking difficulties)
Hearing Impairment
Referrals considered from birth
Referral for children with hearing impairment is always through Audiology or ENT or other specialist tertiary centres.
Severe global developmental delay
Referrals considered from birth
A referral should be considered for early years children with severe developmental delay, however if the child is known to iSEND Early Years Service please discuss with your Early Years practitioner before referring. Referral for school years children with global developmental delay will
Version 1: August 2016
Review date: August 2018
be considered if the language difficulties are impacting significantly on developing functional communication e.g. via Children with Alternative and Augmentative Communication (AAC)
Syndromes affecting neuro development
Referrals considered from birth
A referral should be considered for early years children with syndromes affecting neuro development, however if the child is known to iSEND Early Years Service please discuss with your Early Years practitioner before referring. Referral for school years children with a syndrome affecting neuro development will be considered if the language difficulties are impacting significantly on developing functional communication e.g. via AAC. For all children please see above for eating and drinking guidance
ASD
Referrals considered from 27 months after the integrated health review
SLTs work with Paediatricians as part of the multi-disciplinary assessment pathway (via Paediatrician referral). School years children should be referred if the the language difficulties are impacting significantly on developing functional communication, if there is limited educational progress or to support transition. Schools should be able to provide support for social communication difficulties as part of their local offer.
Cerebral Palsy
Referrals considered from birth
Referral for children with cerebral palsy is always through specialist tertiary centres or within the CITS service
Acquired brain injury
Referrals considered from birth
Referral for children with an acquired brain injury is always through specialist tertiary centres or within the CITS service
Version 1: August 2016
Review date: August 2018
Alternative and Augmentative Communication (AAC)
Children with AAC needs will always have been previously referred because of speech, language or communication needs and the therapist will be able to advise on AAC as part of case management
Version 1: August 2016
Review date: August 2018