Prescribing children's equipment and adaptations 2021 pdf

Prescribing equipment and adaptations for children

Quiz:
What
am I?

Where do
children's
occupational
therapists work?

Home
Schools / education settings
Healthcare settings
Charities
Independent practice

What are children's
meaningful
occupations?

Play & leisure
Life skills
Interactions with others
Personal care
Nutrition
Education

Assessment of children
Does this differ across settings?
Models of practice
Which is most appropriate?

Assessment of children
Does this differ across settings?
PEOP / Developmental / Biomechanical /
Ecological …….
Models of practice
Which is most appropriate?
Yes, and you may vary your approach as the
treatment plan evolves guides
(Kramer, 2018)

You as a children's
occupational
therapist:
A well-stocked
toolbox!

Therapeutic use of self
The considered use of the individual therapists personal traits,
knowledge, skills and experience during therapeutic interactions with
others, with the aim of this being a positive agent of
change. (Solman & Cloughton, 2016)
Intentional Relationship Model
(Taylor, 2008)
Six key interpersonal skills or ‘modes’ of practice:
Advocate, collaborate, empathise, encourage, instruct, problem-solve
… at the appropriate time and dependent on need.
HCPC
‘demonstrate effective verbal and non-verbal communication skills,
understanding the impact of such skills upon the therapeutic process and
be able to move between different means of communication, adapting
in response to the client’s needs and characteristics’. (HCPC, 2013)
Restorative practice
It is based on the general premise that ‘human beings are happier, more
cooperative and productive, and more likely to make positive changes in
their behaviour when those in positions of authority do things
with them, rather than to them, or for them.’ (International Institute of
Restorative Practices 2020)
(Also Hagedorn, 2000 p90)

Therapeutic use of self
What tools do we have to
support us as we assess need
and reassess provision for
children?

Therapeutic use of self
Modifying your approach:
Adopt their level – floor / seating
Adapt your language – avoid medical terms / jargon
Age & stage
Consider sensory aspects
Location – ‘their’ environment (if possible)
Occupations - which are important to them
Use of tools to engage – toys / props
Physical engagement – play, appropriate touch, use your body
as a support
Demonstrate – you complete the activity
To achieve the best outcome we need to engage a child's interest

Therapeutic use of self
Establish rapport:
Child:
Accept their current level of function
Unconditional acceptance
Participation – joint agreement of objectives
Knowledge of their interests, opinions and wishes
Adults:
They support activities after any therapy session
They influence a child’s engagement
Role models
(Parents, carers, teachers, 1:1 support…..)

Therapeutic use of self
(Before we move on)
Reflection and recognition of bias
Relationships between occupational therapy
students’ understandings of disability and disability attitudes
VanPuybrouck & Friedman (2019)
Ageism and Ableism: Unrecognized Biases in Occupational Therapy
Students
Friedman & VanPuymbrouck (2021)

Voice of the child
What does this mean?
How do we elicit it?

Voice of the child
Conversation / discussion
Observation: body language, facial expression & actions
Eye gaze / indication
Makaton
PECS
Objects of reference
Images
Demonstration
Augmentative and alternative communication (AAC)

Play
A key meaningful occupation:
Different types & purposes
Free play:
‘freely chosen, personally directed, and intrinsically motivated, i.e. performed for
no external goal or reward.’ (Bob Hughes, 1982)
Sport
Directed play
Educational
Therapeutic

Participation: Role of equipment / adaptations

Facilitation of occupations:
leisure / study / personal care
Skill acquisition:
Self-feeding, continence
Care provision
Promotion of independence
Sleep
24 hour postural management
Manual handling / transfers
Access
Safety

What are the
differences between
equipment and
adaptations for
adults and children?

Size?
Activity?
Changes in ability?
Carers?

• Process
• Assessment:​
• Provides the information which directs professional reasoning and is the​
‘result of a dynamic interaction of multiple sources of information both
from within the therapist and outside the therapist’
(Copley, Bennett & Turpin, 2017 p350)​

• Process
• Information gathering
• What do we need to know?
• What might we already know?
• Where will we get information from?

• Process
• Diagnosis / disability / history
• Age / size / weight / development
• Reflect changing abilities / condition (+/-)
• Impact of LT needs
• Family
• Carers
• Personal preference
• Expectations
• Remember information gathering is cumulative – assessment gives
a baseline but other sources of information such as EHC plans help create
a full picture

• Process
• Prescription / Recommendation
• Local processes vary but following assessment
• Equipment:
• Consider if ‘contract’ items from the Integrated Community Equipment Service
(ICES) will meet need – cost effective timely provision
• Non-contract equipment may be more appropriate but timescales will be
longer and repair / spare parts / costs should form part of clinical / professional
reasoning
• Adaptation:
• Under £1000 Local authority funding
• Over £1000 Disabled Facilities Grant
• Criteria / Remit / Clinical or professional reasoning / standardised assessments

• Process
• Challenges
• Voice of the child
• Cognition
• Engagement
• Goal setting
• Expectation
• Environmental constraints
• Budget / funding limits
• Consistency between settings
• Preference / choice
• Remit / role / criteria
• Conflict with other therapeutic goals
• Understanding

• Process
• Challenges
What challenges do children's occupational therapists have
when prescribing equipment & adaptations?

Challenges - some solutions:
Voice of the child - body language / facial expression / images / PECS / objects of
reference / Makaton….
Cognition – liaise with school / SALT / never make presumptions
Engagement – use of toys / objects of reference / relevance to child
Goal setting – relevant to the child / achievable
Expectation – remit / explanation / clarity
Environmental constraints – complete assessment in an alternative location / match
equipment to the environment
Consistency between settings – liaison with involved AHP’s / school etc.; acceptance
needs may differ

Challenges - some solutions:
Budget / funding limits – understand the constraints / re-use of equipment / dual
use equipment / compromise (!)
Preference / choice – balance between this /remit / voice of the child. Listen,
understand remit and communicate
Remit / role / criteria – know your role & that of others, what you can provide,
how it is funded, and any relevant criteria
Conflict with other therapeutic goals – liaison with others, discussion with child /
parent, compromise
Understanding – consider age & stage – different approach for child and parents

Case studies
*Evie * Joshua * Kayla * Marcus *

Evie
Evie lives with her mum and dad and twin sister in an owner
occupied 3 bed semi-detached house. She attends special school
and enjoys riding, music, the family dog Benji and family time
especially days out at the coast.
Evie is a full-time wheelchair user as a result of spastic
quadriplegia with high muscle tone. This presents as extensor
spasms often as a result of a startle reflex. She does not have
verbal communication – at 5 she uses facial expression &
vocalisation but by 15 is using eye gaze assistive technology to
communicate.
Evie needs assistance with all activities of daily living & transfers.
5 years old
The issue which the family have identified as most important is access to
bathing.
Look at the Mangar Surfer Bather https://bit.ly/2UM3ska and the Rifton Wave
https://bit.ly/2xvxPU3 and identify the features of these which you would need
to consider before prescribing either.
Is there anything else on the market which you think might be worth
considering?
10 years old
Evie has been carried upstairs to her bedroom by her parents but now they are
ready to consider adaptations and assisted transfers.
Which rooms do you think will need hoist provision?
What are the benefits / disadvantages of a) a mobile hoist & b) a ceiling track
hoist?
Why would you consider a first floor adaptation over a ground floor bedroom /
bathroom extension?
15 years old
Evie is an independent teenager who is clear in her determination to have control
over her life and choices. She is adept at using the eye gaze equipment and in
controlling her powered wheelchair.
What equipment / adaptations do you think will be appropriate to consider now?

Joshua
Joshua lives with his parents and younger brother in a
rented 2 bedroomed bungalow with an integral garage
owned by a family member.
He is an avid football fan supporting his local team and is
active in his local Beavers / Cubs / Scout troop and attends
mainstream school.
Joshua has a diagnosis of Duchenne Muscular dystrophy
(& his brother is undergoing investigations to see if he also
has this diagnosis).
5 years old
Joshua is mobile although a little unsteady and struggles at times to get up from
the floor as he becomes tired easily.
Look at the Breezi seating https://bit.ly/2QTgZoR and the Wombat
https://bit.ly/3aDLffe . Do you think that the Wombat is the right equipment at
this time?
10 years old
Joshua’s brother has now been confirmed as having the same diagnosis. Joshua
has limited mobility and is using a wheelchair more frequently indoors and
always outdoors and in school.
How will this information impact on your decision-making around adaptations?
15 years old
Joshua has used a Flamingo shower chair with a height adjustable
base https://bit.ly/3avf1Dc for both bathing and toileting in the adapted
bathroom.
He cannot manage his intimate personal care independently now and finds the
flamingo uncomfortable when showering.
What equipment / adaptations options are there to maintain Joshua’s
independence, privacy and dignity during personal care activities?

Kayla
Kayla lives with her mother and 4 siblings (2 older boys, 2 younger
twin girls) in a 3 bedroomed terraced house rented from their
District Council.
She does not see her father but is close to her maternal
grandparents who live on the same street. Kayla does not have a
diagnosis but has global developmental delay, frequent seizures
and respiratory infections. She has complex medical conditions
and appears to be in pain but what causes this is unknown. She
has low tone and cannot sit unsupported. She vocalises to
indicate need and enjoys sensory activities.
5 years old
The family are over-crowded in their current home with Kayla sleeping in her
mothers’ bedroom.
You are supporting an application to be re-housed. What are the aspects of a
new property which will need to be highlighted to the council to support the
identification of a suitable property?
10 years old
The family have moved to a 3 bedroomed house with a dining room which has
been utilised as Kayla’s bedroom. Up till now she has been carried upstairs when
she has needed a bath. The family bathroom is a suitable size for altering to
include a level access shower but there are out-buildings which could be
converted to provide a GF shower room.
What options are available to you to meet Kayla’s bathing needs? How will this
affect other family members?
15 years old
Kayla’s condition has deteriorated and she has 2 waking carers overnight 4
nights a week who use in bed slide sheets to reposition her. On the other
nights her mother has to get up numerous times to reposition her to reduce
her pain levels.
Why would this single handed care by Kayla’s mother be a concern?
There are options available to assist her mother with repositioning Kayla. What
are the benefits / disadvantages of the following:
In bed slide sheets https://bit.ly/3dCAvjl
Digital turn mattress replacement https://bit.ly/2UJXXm7 Bed turning system
https://bit.ly/39tdlsu

Marcus
Marcus lives with his parents and younger sister in a there
bedroomed owner occupied house. He attends special school and
has anxiety when his routine is interrupted so the family ensure
that he is taken to familiar places such as the park & supermarket
when he is not at school. He enjoys Thomas the Tank Engine
DVD’s and toys and does not like wearing certain fabrics preferring
loose PJ’s or tracksuits. Marcus has a diagnosis of autism and
global developmental delay communicating through vocalisations
which are inconsistent in their link to his wants or needs. He has
no safety awareness and when he becomes anxious or frustrated
his response is physical hitting his head against the wall or he will
lash out at those near him. He has a poor sleep pattern (less than
5 hours per night) and will shout and bang on the door / walls
until his parents take him downstairs.
5 years old
Marcus’ parents are struggling with his poor sleep pattern. With young children
we would not look to adaptations / equipment to manage behaviours if at all
possible.
What advice would you offer them around changes they can make to his
bedroom which may help with sleep promotion?
Do you think there are any sources of support they can access to help them at
this time?
10 years old
Marcus’ sleep pattern is still poor & he lets himself out of his room at night
& wanders round the house & has turned on the gas fire & flooded the
bathroom. If he cannot access what he wants he does not wake his parents but
will go to his sister’s room & pull her hair & scream at her. If shut in his room he
will head bang / self-harm.
Options to ensure Marcus’ and his sister’s safety are:
Padded cot bed https://bit.ly/2ULkmzj
Padded room https://bit.ly/3bL0VxN / https://bit.ly/2wCcGHX
SafeSpace https://bit.ly/2WTwLnE
What are the benefits / disadvantages of each of these options?
15 years old
Marcus will try and leave the house if he is unsupervised. The house is on a busy
main road but Marcus walks straight out as he wants to go to the park. He
is fascinated by water & has flooded the kitchen, cloakroom & bathroom. What
options can you think of to a) keep him safe &, b) reduce the risk of flooding.
Marcus is almost 16, the Mental Capacity Act 2005 advises those over the age of
16 have the right to make choices about decisions affecting them & their
liberty. https://bit.ly/39sacZU offers advice to parents of those with learning
disabilities.
Should locks can be fitted to the external doors & his bedroom to keep him
safe?

Concluding thoughts
• A snap shot of this area of occupational
therapy practice
• Consider individuals not the diagnosis
• Voice of the child
• On-going re-assessment
• Remember cultural and religious practice
• Holistic – family & child focus
• Engagement
• Compromise

• References​
• Copley, Bennett & Turpin (2017) Decision-making for Occupation-centred Practice
with Children. in Eds Roger & Kennedy-Behr. Occupation-centred Practice with Children.
Chichester: Wiley Blackwell​
• ​Friedman, C. and VanPuymbrouck, L., 2021. Ageism and Ableism: Unrecognized Biases
in Occupational Therapy Students. Physical & Occupational Therapy In Geriatrics, pp.1-16.
• Health and Care Professions Council (2013) Standards of Proficiency: Occupational
Therapists. London: Health and Care Professions Council.​
• Hughes, B., (1982). PlayEducation http://rphughes44.blogspot.com/
• International institute for Restorative Practices https://www.iirp.edu/
• Kramer, P., 2018. Frames of reference for pediatric occupational therapy. Lippincott
Williams & Wilkins.​
• Solman & Clouston (2016). Occupational therapy and the therapeutic use of self.
British Journal of Occupational Therapy. 79(8) 514–516​
• Taylor RR (2008) The Intentional Relationship: Occupational Therapy and Use of
Self. Philadelphia, PA: F.A. Davis Company.​
• VanPuymbrouck, L. and Friedman, C. (2019) Relationships between occupational
therapy students’ understandings of disability and disability attitudes. Scandinavian
journal of occupational therapy.