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Physiotherapy with Children. Movement is important for children’s development and learning. Physiotherapy with Children Significant Gross Motor Development Milestones (GMDM) Red Flags What to encourage? . Physiotherapy=‘physical’ + ‘treatment’. Physiotherapy with Children. Assessment.

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Physiotherapy with Children
  • Significant Gross Motor Development Milestones (GMDM)
  • Red Flags
  • What to encourage?
physiotherapy with children1
Physiotherapy=‘physical’ + ‘treatment’Physiotherapy with Children


Formulate problem list

Block of therapy

Refer to other services

Review and home program

Discharge as appropriate

areas that physiotherapist work on with children
Areas that Physiotherapist work on with children
  • Gross motor development
  • Movement patterns
  • Postures
significant gmdm 6wk 18m
Significant GMDM (6wk-18m)
  • Lift head when on tummy……3m
  • Rolling………………………….4-6m
  • Sitting…………………………..6-8m
  • Crawling……………………….8-10m
  • Standing……………………….9-12m
  • Walking unsupported…………9-18m
tummy play time
Tummy play time
  • Start as early as possible, soon after birth
  • Best before feed, after bath or when well alert
  • A few times a day
rolling 4 6m
Rolling (4-6m)
  • First exciting mobility on the floor
sitting 6 8m
Sitting (6-8m)
  • Sit up to see the world
crawling 8 10m
Crawling (8-10m)
  • Set the foundation for coordination tasks
red flag when babies are
Red flag when babies are
  • looking to one direction most of the time
    • Habit
    • Muscle tightness at the neck
    • Flattened on one side of the back of head

Further flattening of head which lead to asymmetrical head shape (positional plagiocephaly)

Born pre-mature
    • Born equal or less than 34weeks
    • Eg. Baby born at 32wks, when they are 8m, we should expect that the GM dev. will be around 6m
  • Stiff
    • High muscle tone, tight muscles
    • Arching of the body, hard to bend the arms and legs
    • Difficulty in dressing, changing nappies, sitting up
    • Low muscle tone
    • Prefer to lay on their back
    • Dislike tummy time
    • Not eager to move around
    • Sit with a round back
  • Lack of opportunity
    • Consistent to be put in certain position
    • Too much time in baby walker, means inadequate time for tummy play time
‘W’ sitting
    • sit between feet with knees bent

develop pigeon toe walking pattern

  • Constantly stand or walk on tip toes
    • tight calves, high calf muscle tone, habit

delay in walking, shortening of calves

what to encourage
What to encourage?
  • Facilitate baby to look to both directions
  • Provide plenty of tummy play time
  • Perform arms and legs exercises after nappy change
  • Facilitate crawling instead of bottom shuffling
  • Encourage walking along furniture and negotiate obstacles
  • Cross-legged sitting instead of ‘W’ sitting posture
significant gmdm 18m 3yr
Significant GMDM (18m-3yr)
  • Development of balance and emerge of new skills
    • Squatting well…………..18m
    • Jumping on a spot ……..3yr
    • Running safely………….3yr
red flag when children are
Red Flag when children are
  • Falling over excessively
    • poor balance, severe pigeon toed, perceptual issues


  • Walking on tip-toes (80-90% of the time)
    • tight calves, high calf muscle tone, habit

sore calves, decrease walking tolerance, shortening of calves

what to encourage1
What to encourage?
  • Using out-door equipment
    • Swings, slides, climbing frame, tunnel
  • Walking on balance beam (20-30cm wide)
  • Chasing
  • Jumping in the sand-pit
Riding tricycle
  • Kicking and throwing balls
significant gmdm 3 5yr
Significant GMDM (3-5yr)
  • Development of dynamic balance and refinement of gross motor skills
    • Jumping from height safely….5yr
    • Running efficiently……………5yr
    • Stairs walking……………… form
    • Balance on 1leg………………5s for 5yr old
red flag when children are1
Red Flag when children are
  • Falling over on a flat surface
    • Poor balance, pigeon toed
  • Moving with awkward movements
    • Arms and legs looks awkward when the child is running or jumping
    • Poor balance/coordination
  • Having difficulty to stand up from floor
    • Weak trunk muscles
Avoiding physical activities
    • Low muscle tone, vestibular dysfunction, perceptual issues
  • Tiring quickly
    • Low muscle tone
what to encourage2
What to encourage?
  • Walking on narrow beam (10-15cm wide)
  • Kicking and throwing balls to target
  • Simon says
  • Run and freeze game
Using out-door equipment
    • Swings, slides, climbing frame, tunnel
  • Riding bicycle
  • Jumping on bouncy surface
any doubts
Any doubts??
  • Refer to the Queensland Health Developmental check list

physiotherapy services
Physiotherapy services
  • Contact your local community health centre, developmental assessment team or hospital
  • Private Paediatric Physiotherapy services can be obtained through
    • Australian Physiotherapy Association

Queensland branch office (07) 3423 1553

    • Yellow page
what is occupational therapy
What is Occupational Therapy??
  • Common belief that OTs help people return to work following injury or illness.
  • This is only part of the picture.
  • “Occupation” actually refers to any activity that you do during the day
      • Self care activities
      • Work and productive activities (paid/unpaid)
      • Leisure activities
occupation for children
Occupation for children
  • Self care skills – depending on their age can include being able to self feed, dress themselves, or be toilet trained.
  • Children learn and develop most of their skills through play. Therefore for children work and play are the same thing
skills ots typically work on with children
Skills OTs typically work on with children
  • Fine motor skills
  • Visual perceptual and visual motor skills
  • Play skills
  • Sensory processing
  • Self care skills
fine motor skills
Fine motor skills
  • This is using your hands and fingers.
  • These skills allow you to open a jar, undo your shoe laces, do up a button and use a pencil, etc etc.
visual perceptual vp and visual motor integration vmi skills
Visual perceptual (VP) and Visual motor integration (VMI) skills
  • Visual Perception is the brain interpreting what the eyes see.
        • Recognising own name
        • Judging the right way around to put clothes on
        • Knowing which way to hold a book (even if just looking at the pictures)
  • Visual Motor integration is doing something in response to what you see.
        • Draw a picture
        • Do a Puzzle
play skills
Play Skills
  • This includes a range of skills, from basic exploration of toys to more creative play:
      • Cause and effect
      • Teddy/doll play
      • Object Substitution
      • Role playing and story telling
      • Playing with peers
sensory processing
Sensory Processing
  • There are the five typical senses
  • There is also Proprioception (sense of body awareness) and Vestibular (sense of movement)
  • OTs tend to look more at how sensory input impacts on the child as a whole.
self care skills
Self Care Skills
  • Feeding
      • Independent finger feeding
      • Use of cutlery
      • Drinking from a cup
  • Dressing
  • Toileting (note: issues withpersistent bed wetting or soiling tend to be managed by OTs in hospital settings).
red flags
  • All children develop at their own pace and have their own activity preferences.
  • When do you know a child is having a difficulty??
  • See website at end of presentation for checklists.
fine motor red flags
Fine motor red flags
  • 6months
      • No hand or arm use at all.
      • A marked difference between the use of the left and right hands.
      • Not letting go of toys, even when finished playing with it.
  • 12 months
      • Still using whole hand to pick up objects, rather than attempting with fingers first.
      • Not using two hands together.
fine motor red flags cont
Fine motor red flags cont…
  • 18 months
      • Not stacking blocks
      • Cannot use a spoon for feeding
  • 2 years
      • Not interested in pencils
fine motor red flags cont1
Fine motor red flags cont…
  • 3 to 4 years
      • Poor pencil skills (compared with other children the same age)
      • Refuses or avoids fine motor activities
      • Cannot use a fork
      • 4 years – not showing a hand preference (esp. if to start prep in the next year).
vp and vmi red flags
VP and VMI red flags
  • 6 months
      • not reaching for toys
  • 12 months
      • poor ability to self feed (hand to mouth feeding)
  • 18 months
      • unable to use simple insert puzzles or shape sorters
vp and vmi red flags cont
VP and VMI red flags cont…
  • 2 years
      • Unable to copy horizontal or vertical lines (when first drawn by an adult)
  • 3 to 4 years
      • Not drawing simple pictures (may not look like anything but they should be able to tell you what they have drawn)
play red flags
Play red flags
  • 6 months
      • Does not enjoy sensory play (toys with noise, lights and/or texture)
  • 12 months
      • Does not engage in container play
  • 18 months
      • Does not understand simple cause and effect play
play red flags cont
Play red flags cont…
  • 2 years
      • No imaginary play (pretend play with dolls/teddy or imitating adults)
  • 3 to 4 years
      • No imaginary play or very immature play
      • No cooperative play with peers
sensory processing1
Sensory Processing
  • All children need more sensory input than adults, therefore they seem to be constantly seeking input.
  • Sensory processing issues are only a problem if they impact negatively on the activities children either need, or want, to do.
sensory processing red flags
Sensory Processing red flags
  • When a little feels like a lot (over-responsive)
      • Want to wash hands +++ or avoids messy play.
      • Does not like ++ noise
      • Avoids rough and tumble play
      • Does not tolerate other children coming too close.
      • Poor eating – limited range of foods
      • Tends to be very easily upset and over-reacts to situations
sensory processing red flags cont
Sensory Processing red flags cont…
  • When a lot feels like a little (under-responsive
      • Constantly “on the go”
      • Seeks messy, noisy and/or rough and tumble play.
      • Alternatively may need a lot of input to get going and may appear quite passive.
      • Can be intrusive into others personal space
      • Can have poor attention
self care red flags
Self Care red flags
  • 12 months
      • Not self feeding
  • 2 years
      • Not using cutlery; Not drinking from a cup
  • 3 to 4 years
      • Not able to manage clothes for toileting
      • Not dry by day (by 4 years)
ot services
OT services
  • QLD Health OT services vary from district to district. Contact your local community health centre or hospital for details on services
  • It is important to know the eligibility criteria – some services need GP or Paediatrician referrals, while others take self referral.
ot services cont
OT services cont…
  • Private OT services
      • Yellow pages
      • Contact OT Australia QLD on 3397 6744
Children are spending longer hours in child care than ever before.
  • The quality of the interactions they have at child care can make a difference to a child’s communication development
effective communication skills mediate success in all social relationships
Effective communication skills mediate success in all social relationships

The Primary means of establishing and maintaining social relationships is through the use of language

Recent studies of the impact ofadult-mediated strategies in day care and preschool settings have been shown to improve communication for children with delayed or disordered language skills

What is a Speech Pathologist
  • ‘Red Flags’: language development especially under <3yrs
  • Communication styles: children
  • Strategies to aid communication
    • Observe wait and listen
    • Face to face communication
what is a speech pathologist
What is a “Speech Pathologist”?
  • Same as a ‘Speech Therapist’
  • Treat children who stutter and lisp
  • But, we also do a whole lot more!!
a speech pathologist
A Speech Pathologist:
  • Assesses and treats children and adults
  • Speech (sound production)
  • Fluency (stuttering)
  • Voice
  • Feeding
Language: receptive and expressive
    • Semantics (word meaning)
    • Syntax (grammatical structure)
    • Pragmatics (social use of language)
  • These areas of difficulty may exist as separate conditions OR may be part of a more global/developmental problem.
public speech pathology
Public Speech Pathology:
  • Some services have long waiting lists.
  • Specific inclusion criteria e.g. In the West Moreton District we prioritise children under 3 y.o. seen < 3months
  • The earlier a referral is made the better
paed speech at wmsbd 3 y o
Paed Speech at WMSBD: < 3 y.o

If referral accepted

Referral to other disciplines

Questionnaires returned

Waiting list < 3 months

Hanen program

Monitor and review

Full assessment

Block of treatment


Referral to other agency

referrals generally
Referrals – generally
  • Generally parents can refer to Community Health Centres
  • Generally parents need to get a GP’s referral to be referred to a Hospital Speech Pathologist (varies a lot)
prevalence of sli
Prevalence of SLI
  • Parents and teachers are very accurate at identifying children with difficulties
  • About 16.3% of all children will have a communication difficulty
  • 47.5% will have difficulties in more that one communication area
  • Comorbidities are common (gross or fine motor difficulties)
developmental continuums
Developmental Continuums
  • Check your text books about the milestones for babies, toddlers and young children.
  • ‘Red Flags’
delay disorder difference
  • Some researchers saying that:
    • Delay = <3yrs
    • Disorder = >3yrs
outcomes for children with sli
Outcomes for children with SLI:
  • Children with language disorder at 5yrs have poor outcomes:
      • learning difficulties
      • antisocial adolescent behaviour
      • limited vocational opportunities
  • Children with speech only difficulties have similar outcomes as children with normal speech and language development.
take home message
Take home message:
  • It is important to be on the look out for the indicators of language delay (ages 1-3yrs) as these children are most at risk of the life long implications of language disorder.
red flags 12mths
Red Flags - 12mths
  • Definite indicators of children at risk of language delay before they start talking
  • Look for:
      • Babbling
      • Pragmatic skills
      • Language comprehension
      • Play skills
babbling 12 months cont
Babbling – (12 months cont)
  • The more the better
  • Why?
      • Sound practice (basis of early words)
      • Increased response from care givers
  • Listen for:
      • amount
      • number of different sounds
      • reduplicated and variegated
      • accuracy of production
pragmatic skills 12 months cont
Pragmatic Skills (12 months cont)
  • Indicates social motivation
  • Look out for:
    • eye gaze (engaging in eye contact)
    • social greetings (hello and goodbye)
    • facial expression (showing they enjoy interaction)
    • requesting and protesting (using pointing)
language comprehension 12 m
Language Comprehension (12 m)
  • Usually develops before expression
  • Age appropriate comprehension is a positive indicator that language skills will develop
  • Delays of >6mths indicates a more persistent difficulty
red flags 2yrs
Red Flags - 2yrs
  • 10-15% of 2yos will have an obvious delay in language development
  • Look for:
    • delayed language comprehension
    • restricted vocabulary
    • word combinations
    • speech
language comprehension 2 y o
Language comprehension – 2 y.o
  • At 2yrs a child’s language comprehension should be on par with same aged peers
  • Any delay indicates a child is at risk
  • A delay >6mths is a strong indicator of a persistent or more global difficulty
restricted vocabulary 2 y o
Restricted Vocabulary – 2 y.o.
  • Expect a child at 2yrs to have a vocabulary of more than 50 words
word combinations 2 years
Word combinations – 2 years
  • Expect a child at 2yrs to be using some two word combinations
speech at 2 years old
Speech at 2 years old
  • 26-50% intelligible
  • wide range of sound errors still acceptable
  • look out for:
    • vowel errors
    • use of /h/ for other consonants
red flags 3yrs
Red Flags - 3yrs
  • 60% of delayed 2yos will have recovered
  • at 3yo, the group of delayed children is smaller and more at risk - ‘disorder’
  • speech should be 73% intelligible
    • ok if intelligibility decreases in complex sentences
    • range of errors still acceptable
refer at 3yrs if
Refer at 3yrs if:
  • A child is unintelligible
  • a child doesn’t use or understand concepts, words or sentences
  • a child doesn’t engage with other children in a social/communicative way
  • a child isn’t interested in concepts, how and why, or stories (including retell)
4 6yrs
  • Be guided by charts/developmental checklists
  • at this age, it is increasingly unlikely that a child will ‘outgrow’ their difficulties
  • at risk of ongoing difficulties at school
  • Don’t delay referrals
have a little think about
Have a little think about…….
  • Which children do you most enjoy interaction with? (what are their conversational styles?)
  • Which children do you interact with the least? (What are their conversational styles?)
children s interaction styles
Children’s interaction styles
  • Reluctant/shy style
  • Passive style
  • Own Agenda
  • Sociable

Adults have their own styles too!!

i really hate it when i am talking with someone and they
I really hate it when I am talking with someone and they…..
  • Don’t listen to what I’m saying
  • Interrupt
  • Don’t look at me
  • Take over the conversation and I can’t get a word in
  • Just keep telling me what to do
  • Wait
  • Listen
give a reason to communicate wait
Give a reason to communicate & wait!
  • Wait and see what the child will do: avoid the helper role
  • Place a desired object in view but out of reach
  • Introduce a hard-to-operate object
  • Offer things bit by bit
  • Do the unexpected
a very simple way to connect
A VERY simple way to connect…
  • BE FACE TO FACE!!! 
think about
Think about…
  • Identify four children from your class that display the four different conversational styles.
if you have a concern about a child
If you have a concern about a child..
  • Can be difficult but definitely worth approaching the parent!
  • Before you approach parent:

1. Have a checklist with you. Developmental checklists can be obtained from

2. Know what services are available

- phone local hospital, community health service, yellow pages for private SPs.

discussing with parents con t
Discussing with parents… con’t
  • Develop rapport first
  • Maybe first time parent has had anyone say something might be wrong with their child
  • Refer back to checklist – keeps it objective
  • Address with concern for the child
  • Give parents time to think about it/discuss with partner
  • Follow up. Could suggest that they get an opinion because better to be safe than sorry.
discussing with parents con t1
Discussing with parents… con’t
  • Sometimes can take a while for a parent to ‘come ‘round’.
  • Sometimes they don’t turn up for us OR don’t come back after first session, but then turn up again e.g. 12 months later
  • Most parents will appreciate your interest in their child if done compassionately.
teacher talk workshop
Teacher Talk Workshop
  • International Speaker: Anne McDade, Speech Pathologist, Hanen Trainer
  • Encouraging Language Development in Early Childhood Settings
  • Saturday 1st September
  • Wilston, Brisbane
teacher talk seminar cont
Teacher Talk Seminar cont
  • Audience: Teachers & Teacher Aides in Child Care Settings, SEDU, Prep
  • $110 per person, includes workbooks, lunch, morning & afternoon tea
  • Contact for more information: