Background

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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

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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
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Scholarship of Practice Philosophy

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Who is in the DCD research team?
Academia
Practice
ACHIEVE Alliance
The ACHIEVE Alliance Active in Childrens
Health Integrating Evidence, Valuing
Experiences
Dr Howden
K Flannery
C Shephard
Dr Maciver
N ONeill
R Rush
C Owens
M Hill
M Curl
S Sommer
Prof Law
A Adamson
Prof A OHare
Prof Kvitz
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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
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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
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How will scientific evidence be appraised?
Appraisal Scientific Evidence
Evidence Perspective
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
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Service User Perspective
Focus groups with parents/ guardians
Progress Report Parent/Guardian Child Focus
Groups
Focus groups with children
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Service User Perspective
Focus groups with parents/ guardians
Achieved Parents Guardians/Children
Focus groups with children

• Multi-site Research Ethics Committee
• For every health board area
• RD Approval
• Complete Disclosure Scotland
• Honorary Contract
• Identifying local AHP recruitment person
• Identifying AHP innovative practice
• Set up methodology for child focus groups

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Children Focus Groups
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Children Focus Group Drawings
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Children Focus Group Drawings
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Children Focus Group Drawings
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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
• Confidence self esteem happiness self belief
  when engaging in new activities
• Children want to improve in
• Specific activities enable participation with
  peers through recreation
• Identified school as being difficult and
  something they were bad at want to improve

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

• Parents View of Service
• Positive
• 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

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

• What could be done to improve service
• Improved accessibility of therapy support
• Promote seamless care
• Provision of quality care at school in their
  locality
• Communication and parent/carer involvement
• Improving the consistency of therapists knowledge

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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

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Professional Perspective
AHP Survey
Progress Report AHP Survey Depth interviews
Depth interviews With AHPs
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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

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AHP Survey Structure
Professional Perspective
AHP Survey
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Achieved AHP Survey Repeated Administrations
Professional Perspective
AHP Survey
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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
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Percentage of respondents who have DCD children
on their caseload 209/391 54
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Percentage of each professions
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NHS Board area of AHPs who have DCD children on
caseload
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(No Transcript)
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Who do you accept referrals from?
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How FREQUENT and APPRORIATE are referrals?
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Screening/Triage
33
How FREQUENT and EFFECTIVE is cross profession
triage
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Gaining Consent
35
Format of consent
36
Assessment Joint working
37
Assessment Location
38
Communicating Assessment Findings
39
Parental/Child Involvement
40
Parental/Child Involvement
41
Intervention Location
42
Intervention
43
Evaluation
44
Discharge
45

• Request
• Review survey results
• dmaciver_at_QMU.ac.uk

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Professional Perspective
AHP Survey
Progress Report AHP Survey Depth interviews
Depth interviews With AHPs
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Achieved AHP Interviews
Professional Perspective
AHP Survey

• Identified therapists for interview
• Scoping national AHP managers
• Self identified through survey
• Scoping local authorities
• Audio recorded interviews
• Verbatim transcription
• Analysis through software

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AHP Depth Interviews (n26)
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What did we find?

• Child Focused Care
• Participation in Life
• Skills Knowledge
• Involvement of parent/carers
• Working Together

• Best Practice

Innovation
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Promoting Child Focused Care

• Best Practice
• Understand child's life and what is important to
  them
• Setting goals with child before therapy starts

• Innovation
• Measure childs perceptions before and after
  intervention as outcome of therapy
• Use specialised tools to support child to share
  their view

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Illustration

• Use of Child Reflective Tool as Therapy Outcome
• Measure childs perception of their abilities
  before and after intervention and use the childs
  perception of change to formally judge if therapy
  was effective for child.
• Outcome Focus outcome of intervention is based
  on child's view
• Use of tools to develop goals with child
• Support child to identify what they want to work
  on in therapy
• Outcome child committed to therapy as it has
  relevance to their life

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Promoting Child s Participation in Life

• Innovation
• Facilitate engagement of children with a physical
  leisure responsibility in their community that
  has potential to
• Improve childs sense of their competence within
  physical activities in which they aspire to
  achieve
• Encourage life long interest in exercise
• Greater engagement with peers in their community

• Best Practice
• Using functional activities as the basis for
  motor skills interventions

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Illustration

• Neighbourhood Cycle Group
• Therapist working with a cycle coach to support
  children gain experiences of success in moving
  their body within valued biking activity along
  side peers in their community.
• Outcomes
• Entered group with no/poor bike skills all
  children were able to ride bikes following group
• Child cited examples of having more opportunities
  to cycle with friends
• Emotional feedback from parents about children
  succeeding in where they had previously failed.

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Skills Knowledge Relative to Peers

• Best Practice
• Knowledge of DCD relative to your area of
  paediatric practice
• Therapists being aware of how to refer to
  specialist services

• Innovation
• Developing specialist knowledge related to DCD
  and be perceived by peers as more knowledgeable
• Uncommon for some AHP profession to have
  specialist knowledge of DCD.

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Illustration

• Visual Stress Clinic
• Clinic to screen DCD children to understand if
  their movement challenges are related to their
  vision provide specialist intervention e.g.,
  eye exercises
• Outcome Child have improvement in reading,
  writing and school work.
• Dietetic Intervention
• Increasing parents knowledge of potential role of
  diet in remediation of challenges
• Outcome Children have seen improvement in
  reading, writing and behaviour

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Parent/Carer Involvement

• Best Practice
• Making parents feel heard understood
• Service is flexible, accessible responsive to
  parents
• Facilitation of parental professional
  collaboration
• Explicit support of parents
• Provide information in timely manner

• Innovation
• Facilitation of parent to parent support
• Parental support built into child group
  intervention
• Explicitly shaping parents expectations of their
  responsibilities within intervention
• Formal educational sessions for parents

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Illustration

• Carers Clinics
• Block of group therapy for child and in first
  session parent views child engaging in activities
  therapist narrates reasons for challenges and
  how to intervene effectively
• Goals set collaboratively with parents/children
  and Care Agreement is signed
• Outcomes
• Increase parent and child involvement in goal
  setting Increased parental participation in
  carry over at home
• Parent Consultation Groups
• Block of group therapy for child with first
  session specific to the parents support needs in
  order for the parents to have the opportunity to
  create informal support network
• Outcomes
• Development of informal parental support network

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Working Together

• Best Practice
• Working in effectively collaboration with health,
  education and voluntary sectors

• Innovation
• Emphasis at regional and strategic level that DCD
  is local priority
• Formalised collaboration between multiple
  agencies
• Development of guidance to support collaboration
• Setting up collaborative opportunities by
  accessing non traditional sources of funding
• Providing more variation in AHP options

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Illustration

• Remote collaborative working Motor skill
  screening leading to identification of entry into
  school run movement groups.
• Therapy Inclusion Project Multi professional
  support for education to facilitate children
  access curriculum in classrooms
• Joint Working Project Service for DCD children
  within 13 schools joint OT/PT assessment and
  learning assistants to carry out programs
• PE Movement Program Regional collaborative
  movement program between OT and PE specialist
• Outcomes
• Greater integration of approach between health
  and education
• increased frequency of intervention is perceived
  to get faster results sustains motivation
• Sustainability of programs
• Facilitation of support staff skills/ Effective
  use of therapists time

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

Systematic Literature Review
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Systematic Literature Review
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Systematic Literature Review
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Systematic Literature Review
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Nature of Interventions in Literature

Systematic Literature Review
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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

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Design Quality of All Studies (n50)

Systematic Literature Review
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Findings Overview Summary

Systematic Literature Review
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Summary Higher Quality Findings

Systematic Literature Review

• Perceptual Motor Training and Sensory Integration
• Comparable effectiveness to each other 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

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Summary Higher Quality Findings

Systematic Literature Review

• 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
• 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

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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

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MIXED METHOD SYNTHESIS
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Nature of Qualitative Literature

Systematic Literature Review
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• I have strong opinions about which activities I
  would like to be better at (examples self care
  leisure school work)
• These can differ from parents views
• (Dunford, 2005)

Children's Views
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• Confusion about how to care for their child
• How much should they help, support child to
  avoid activities, leave child to master it on
  their own (Missiuna,
  2006)
• Feeling guilty about their parenting role
• Guilty they may not be doing all that they can
  as a parent
• (Chia, 1997 Pless, 2001)
• Uncertainty in the pre-diagnosis phase
• Fears of something that is not right but unsure
  what is wrong
• (Chia, 1997 Missiuna, 2006)

PARENTS/GUARDIANS VIEWS
77

• Observing the child failing in social situations
• Observing challenges in participating in
  numerous social situations and this being a
  significant negative facets of childs
  condition (Chia, 1997 Segal,2002
  Mandich,2003 Rodger, 2005)
• Belief child has eroded sense of self
• They view their child as having a lack of self
  confidence due to inability to participate in
  activities and being excluded by peers and
  being vulnerable to bullying or teasing
• (Mandich, 2003 Rodger, 2005)
• Observing distinct motor difficulties
• Relative to other children
• (Pless, 2001 Rodger,2005)

PARENTS/GUARDIANS VIEWS
78

• Struggling to access help
• Report their concerns are trivialised and at
  time disregarded and this goes with frustration
  and anger
• (Pless,2001 Mandich,2003 Rodger,2005
  Missiuna, 2006)
• Valuing child centred therapy outcomes
• Value of positive outcomes related to goals
  the child had selected usually skills to allow
  child to re enter participation with peers.
• (Mandich, 2003)

PARENTS/GUARDIANS VIEWS
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MIXED METHOD SYNTHESIS
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MIXED METHOD SYNTHESIS

• Parents ability to observe and identify child's
  difficulties further
• supports their ability to support therapy.
• There is a need to support parents to increase
  their
• understanding about how they can help their child

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MIXED METHOD SYNTHESIS

• Highlights the importance of using child selected
  goals
• (which differ from parents)
• Supports the cognitive intervention which is
  focused on
• child selected goals

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MIXED METHOD SYNTHESIS

• Qualitative studies support the use of cognitive
  and task
• orientated therapies (setting child goals
  resulting in more
• child centred outcomes
• Maybe more likely to impact social participation
  confidence

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MIXED METHOD SYNTHESIS

• Two high quality dietetic studies show
  improvements in areas
• such as school work which was reported to be
  important by
• the child in qualitative studies

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MIXED METHOD SYNTHESIS

• Qualitative literature highlights lack of support
  from parent
• point of view. Parental support not addressed
  within
• quantitative literature
• Few studies used activity or participation
  outcome measures
• to assess efficacy of intervention and change is
  reported in
• Terms of motor skills

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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
86

• Questions?
• Discussion

87
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