Background

1





2
Background

• NHS Scotland argue - should have an AHP
  framework for implementing evidence into practice
• Not emerged for DCD
• Lack of summary of scientific evidence
• Current standard and innovative practice not been
  formally captured

3
Academic LeadDr Kirsty Forsyth
Senior Lecturer, Queen Margaret University
College Research Specialist, University of
Illinois, Chicago Director of UK Centre for
Outcomes Research and Education, London
Advanced MSc, Occupational Therapy PhD,
Public Health Sciences, Chicago National
Network Derby London, Coventry
Gloucester International Network Chicago,
USA Quebec, Canada Stockholm, Sweden Tokyo,
Japan
4

Scholarship of Practice Philosophy

5
Who is in the DCD research team?
Academia
Practice
DCD Research Team ACHIEVE Alliance
The ACHIEVE Alliance Active in Childrens
Health Integrating Evidence, Valuing
Experiences
Dr Howden
C Shephard
Dr Maciver
C Owens
R Rush
Prof Law
A Adamson
Prof Kvitz
Dr A OHare
6
Aims

• Identify what evidence is currently available
• Identify current models of service delivery
• Identify a criteria or framework that would
  indicate clinically effective practice.

Current Practice
Appraise Scientific Evidence
Research Team
Improving Quality of DCD Practice An AHP
Framework
7
How are we capturing current practice?
Professional Perspective
Service User Perspective
Focus groups with parents/ guardians
AHP/LA Survey
Current Practice
Depth interviews with AHPs
Focus groups with children
8
How will scientific evidence be appraised?
Evidence Perspective
Appraisal Scientific Evidence
Systematic Literature Review
9
Current Practice Service User
Perspective
Focus groups with parents/ guardians
Focus groups with children
Evidence Perspective
Systematic Literature Review
Improving Quality of DCD practice An AHP
Framework
Current Practice Professional
Perspective
AHP/LA Survey
Depth interviews With AHPs
10
Progress Report
11
Professional Perspective
AHP Survey
Progress Report AHP Survey
12
AHP Survey Structure
Professional Perspective
AHP Survey
13
Achieved AHP Survey
Professional Perspective
AHP Survey

• Created a modular AHP survey
• Contacted expert in area developed pilot
• Identified national mailing list
• Identified AHP to pilot survey
• Put pilot in field
• Reviewed survey based on pilot feedback
• Repeated administrations

14
Achieved AHP Survey Repeated Administrations
Professional Perspective
AHP Survey
15
Future Actions Analysis
Professional Perspective
AHP Survey
16
Future Actions Analysis
Professional Perspective
AHP Survey

• What is most frequent practice?
• What is most effective practice?
• What is less frequent very effective practice?

Across Profession
Each Profession
Geography
17
Service User Perspective
Focus groups with parents/ guardians
Professional Perspective
AHP Interviews
Progress Report Parent/Guardian Child Focus
Groups AHP Interviews
Focus groups with children
18
Achieved Focus Groups and Interviews
Service User Perspective
Focus groups with parents/ guardians
Professional Perspective
AHP Interviews
Focus groups with children

• Targeting all health board areas
• Child Approval Process Completed
• Ethical Approval, RD approval, Disclosure
  Scotland, Honorary Contract
• Identifying local AHP recruitment person
• Identifying AHP innovative practice
• Set up methodology for child focus groups

19
Child Focus Group Methods
Service User Perspective
Focus groups with parents/ guardians
Professional Perspective
AHP Interviews
Focus groups with children
Academia
Practice
Focus Group Methodology
20
Child Focus Group Methods
Service User Perspective
Focus groups with parents/ guardians
Professional Perspective
AHP Interviews

• Warm up Activities
• encourage verbal interaction
• Therapy Picture Cards
• used as memory joggers
• Drawing Game
• their perception of therapy
• Post it Game
• 3 things they find difficult at home or school
• 3 things they would like help with at home or
  school
• Drawing/Writing Game
• one thing that would make therapy better
• what they wanted to be better at

Focus groups with children
21
Focus Groups and Interviews Process
Service User Perspective
Focus groups with parents/ guardians
Professional Perspective
AHP Interviews
Focus groups with children

• 90 of interviews and focus groups completed
• Audio recording
• Verbatim Transcription
• Analyse data
• Identify key messages

22
Children Focus Groups
23
Children Focus Group Drawings
24
Children Focus Group Drawings
25
Children Focus Group Drawings
26
Children Focus Group Drawings
27
Children Focus Group Drawings
28
Children Focus Group Drawings
29
Children Focus Group Writing Activity
30
Children Focus Group post it Game
31
Initial Observations Parent/Child Focus Groups
Service User Perspective
Focus groups with parents/ guardians
Focus groups with children

• Keen to share their views
• Parents emotional content
• Exchange of information need for peer support
• Children talked freely about their views
• Children data varied verbal, written,
  pictorial

32
Parent/Child Initial Findings
Service User Perspective
Focus groups with parents/ guardians
Focus groups with children

• Parents want to see their child improve in
• Doing home, school activities to increase social
  inclusion
• Concentrate in class keep up academically with
  peers ride bike swim run interact with
  friends dressing using cutlery
• Having friends and being accepted by peers
• Confidence self esteem happiness self belief
  when engaging in new activities
• Children want to improve in
• Specific activities enable participation with
  peers through recreation
• Riding bike playing football martial arts
  basketball
• Identified school as being difficult and
  something they were bad at want to improve

33
Parent/Child Initial Findings
Service User Perspective
Focus groups with parents/ guardians
Focus groups with children

• Parents View of Service
• Positive Empathetic, supportive, caring
  therapists
• Assessment involves parents appears rigorous
• Interventions enjoyed by child positive changes
  observed as result enabled parent to assume a
  therapy role at home
• Negative
• Long waiting times limited therapy input some
  conflicting information from different
  therapists lack of communication between
  professionals variable standard of knowledge
• Children View of Service
• Positive
• Fun, exciting enjoyed one to one interaction
  with therapists therapy understood to help with
  balance, muscles coordination
• Negative
• Initially felt nervous, some assessment
  activities described as embarrassing

34
Parent Initial Findings
Service User Perspective
Focus groups with parents/ guardians

• Parents what could be done to improve service
• Improved accessibility of therapy support
• Locality based, timely and comprehensive
• Needing access to a therapist they trust felt
  was knowledgeable for guidance, information
  reassurance, following discharge
• Promote seamless care
• One therapists as key source of information
  communication seamless information passes from
  one teacher to the next strong liaison between
  therapy and school information passed and acted
  on from primary to secondary school maternity
  leave/sickness lack of consistency
• Provision of quality care at school in their
  locality
• All teachers are knowledgeable about DCD,
  equipped with knowledge practical skills to
  support child all schools be able to access
  equipment
• Transition into secondary school disorientation
  of child, change of teachers, multiple teachers
  involved, lack of communication, timetable,
  moving rooms
• Communication and parent/carer involvement
• Communicate using simple understandable terms
• Communicate frequently on progress and management
  plans
• Improving the consistency of therapists
  knowledge
• Parents appraise the level of knowledge across
  different AHPs

35
Child Initial Findings
Service User Perspective
Focus groups with children

• Child what could be done to improve service
• Increase doing outdoor activities
• Increase help with school activities
• Increase games and play

36
Evidence Perspective
Systematic Literature Review
Progress Report Systematic Review
37
MIXED METHOD SYNTHESIS
38
Search Strings

Systematic Literature Review
39

Systematic Literature Review
40

Systematic Literature Review
41

Systematic Literature Review
42
Authors of Literature by professions

Systematic Literature Review
43
Nature of Interventions in Literature

Systematic Literature Review
44
Grading Quality(van Tulder, 1997)

Systematic Literature Review

• All articles reviewed by two reviewers
• Reviewed for a range of methodological issues and
  graded for quality
• Higher Quality Randomised Control Trial
• Lower Quality Randomised Control Trial
• Higher Quality Control Trial no randomisation
• Lower Quality Control Trial no randomisation
• Sufficient Quality Other Designs
• Low Quality Other Designs

45
Design Quality of All Studies (n50)

Systematic Literature Review
46
Findings Overview Summary

Systematic Literature Review
47
Perceptual Motor Training

Systematic Literature Review
48

Systematic Literature Review
Sensory Integration Therapy
49

Systematic Literature Review
Task Orientated Therapy
50

Systematic Literature Review
Kinaesthetic Training
51

Systematic Literature Review
Cognitive Interventions
52

Systematic Literature Review
Provision of Orthotics
53

Systematic Literature Review
Fatty Acid Supplementation
54

Systematic Literature Review
Reflex Inhibition Exercises Optometric Vision
Therapy
55

Systematic Literature Review
Motor Imagery Training
56

Systematic Literature Review
Multi-Sensory Training
57
Summary Higher Quality Findings

Systematic Literature Review

• Perceptual Motor Training and Sensory Integration
• Both show comparable effectiveness to each other
  and similar treatments on improving motor skills
• Both more effective than no treatment on
  improving motor skills
• Kinaesthetic Training
• Contradictory findings. Comparing kinaesthetic
  training with other approaches showed
  comparable/greater effectiveness, however, other
  studies show no effect relative to no treatment
• Task Orientated Therapy
• More effective than no treatment at improving
  motor skills perceived motor competence and
  shows comparable effectiveness with perceptual
  motor therapy
• Cognitive Interventions
• Verbal self guidance techniques are more
  effective than traditional OT or gross motor
  activities in improving self selected goals and
  motor skills
• Fatty Acid Supplement
• High quality RCT showing fatty acid supplement
  improved reading, spelling behaviour no
  evidence of improved motor skills, however, lower
  quality showed fatty acid supplements improved
  motor skills
• Motor Imagery Training
• Motor imagery training equally beneficial as
  perceptual motor training on improving motor
  skills

58
Summary Lower Quality Findings

Systematic Literature Review

• Reflex Inhibition Exercises Optometric Vision
  Therapy
• May improve oculomotor control, eye movements,
  reading, visual motor/visual perception life
  skills
• Multi Sensory Training
• Multi sensory training may improve writing
  quality and speed
• Orthotics
• Provision of orthotics may be of benefit to
  improve motor skills, foot alignment, posture
  balance
• All interventions above
• Show promise - require control trials and
  randomised control trials

59
MIXED METHOD SYNTHESIS
60
Current Practice Service User
Perspective
Focus groups with parents/ guardians
Focus groups with children
Evidence Perspective
Systematic Literature Review
Improving Quality of DCD practice An AHP
Framework
Current Practice Professional
Perspective
AHP/LA Survey
Depth interviews With AHPs
61

• Questions?
• Discussion

62
Current Practice Service User
Perspective
Focus groups with parents/ guardians
Focus groups with children
Evidence Perspective
Systematic Literature Review
Improving Quality of DCD practice An AHP
Framework
Current Practice Professional
Perspective
AHP/LA Survey
Depth interviews With AHPs
63
Professional Perspective
AHP Survey
Progress Report AHP Survey
64
Achieved AHP Survey Repeated Administrations
Professional Perspective
AHP Survey
65
Future Actions Analysis
Professional Perspective
AHP Survey
66
Future Actions Analysis
Professional Perspective
AHP Survey

• What is most frequent practice?
• What is most effective practice?
• What is less frequent very effective practice?

Across Profession
Each Profession
Geography
67
Service User Perspective
Focus groups with parents/ guardians
Professional Perspective
AHP Interviews
Progress Report Parent/Guardian Child Focus
Groups AHP Interviews
Focus groups with children
68
Parent/Child Initial Findings
Service User Perspective
Focus groups with parents/ guardians
Focus groups with children

• Parents want to see their child improve in
• Doing home, school activities to increase social
  inclusion
• Concentrate in class keep up academically with
  peers ride bike swim run interact with
  friends dressing using cutlery
• Having friends and being accepted by peers
• Confidence self esteem happiness self belief
  when engaging in new activities
• Children want to improve in
• Specific activities enable participation with
  peers through recreation
• Riding bike playing football martial arts
  basketball
• Identified school as being difficult and
  something they were bad at want to improve

69
Parent/Child Initial Findings
Service User Perspective
Focus groups with parents/ guardians
Focus groups with children

• Parents View of Service
• Positive Empathetic, supportive, caring
  therapists
• Assessment involves parents appears rigorous
• Interventions enjoyed by child positive changes
  observed as result enabled parent to assume a
  therapy role at home
• Negative
• Long waiting times limited therapy input some
  conflicting information from different
  therapists lack of communication between
  professionals variable standard of knowledge
• Children View of Service
• Positive
• Fun, exciting enjoyed one to one interaction
  with therapists therapy understood to help with
  balance, muscles coordination
• Negative
• Initially felt nervous, some assessment
  activities described as embarrassing

70
Parent Initial Findings
Service User Perspective
Focus groups with parents/ guardians

• Parents what could be done to improve service
• Improved accessibility of therapy support
• Locality based, timely and comprehensive
• Needing access to a therapist they trust felt
  was knowledgeable for guidance, information
  reassurance, following discharge
• Promote seamless care
• One therapists as key source of information
  communication seamless information passes from
  one teacher to the next strong liaison between
  therapy and school information passed and acted
  on from primary to secondary school maternity
  leave/sickness lack of consistency
• Provision of quality care at school in their
  locality
• All teachers are knowledgeable about DCD,
  equipped with knowledge practical skills to
  support child all schools be able to access
  equipment
• Transition into secondary school disorientation
  of child, change of teachers, multiple teachers
  involved, lack of communication, timetable,
  moving rooms
• Communication and parent/carer involvement
• Communicate using simple understandable terms
• Communicate frequently on progress and management
  plans
• Improving the consistency of therapists
  knowledge
• Parents appraise the level of knowledge across
  different AHPs

71
Child Initial Findings
Service User Perspective
Focus groups with children

• Child what could be done to improve service
• Increase doing outdoor activities
• Increase help with school activities
• Increase games and play

72
Evidence Perspective
Systematic Literature Review
Progress Report Systematic Review
73
MIXED METHOD SYNTHESIS
74
Summary Higher Quality Findings

Systematic Literature Review

• Perceptual Motor Training and Sensory Integration
• Both show comparable effectiveness to each other
  and similar treatments on improving motor skills
• Both more effective than no treatment on
  improving motor skills
• Kinaesthetic Training
• Contradictory findings. Comparing kinaesthetic
  training with other approaches showed
  comparable/greater effectiveness, however, other
  studies show no effect relative to no treatment
• Task Orientated Therapy
• More effective than no treatment at improving
  motor skills perceived motor competence and
  shows comparable effectiveness with perceptual
  motor therapy
• Cognitive Interventions
• Verbal self guidance techniques are more
  effective than traditional OT or gross motor
  activities in improving self selected goals and
  motor skills
• Fatty Acid Supplement
• High quality RCT showing fatty acid supplement
  improved reading, spelling behaviour no
  evidence of improved motor skills, however, lower
  quality showed fatty acid supplements improved
  motor skills
• Motor Imagery Training
• Motor imagery training equally beneficial as
  perceptual motor training on improving motor
  skills

75
Summary Lower Quality Findings

Systematic Literature Review

• Reflex Inhibition Exercises Optometric Vision
  Therapy
• May improve oculomotor control, eye movements,
  reading, visual motor/visual perception life
  skills
• Multi Sensory Training
• Multi sensory training may improve writing
  quality and speed
• Orthotics
• Provision of orthotics may be of benefit to
  improve motor skills, foot alignment, posture
  balance
• All interventions above
• Require control trials and randomised control
  trials

76
Current Practice Service User
Perspective
Focus groups with parents/ guardians
Focus groups with children
Evidence Perspective
Systematic Literature Review
Improving Quality of DCD practice An AHP
Framework
Current Practice Professional
Perspective
AHP/LA Survey
Depth interviews With AHPs