sign in sign up
<<
Home , Physical therapy

CLINICAL REPORT Guidance for the Clinician in Rendering Pediatric Care

Prescribing Physical, Occupational, and Speech Services for Children With Amy Houtrow, MD, PhD, MPH, FAAP, FAAPMR,a Nancy Murphy, MD, FAAP, FAAPMR,b COUNCIL ON CHILDREN WITH DISABILITIES

Pediatric care providers are frequently responsible for prescribing abstract physical, occupational, and speech and monitoring therapeutic progress for children with temporary or permanent disabilities in their practices. This clinical report will provide pediatricians and other pediatric aDepartment of Physical and Rehabilitation and , providers with information about how best to manage the University of Pittsburgh, Pittsburgh, Pennsylvania; and bDivision of therapeutic needs of their patients in the medical home by reviewing the Pediatric Physical Medicine and Rehabilitation, Department of International Classification of Functioning, and Health; describing the Pediatrics, University of Utah, Salt Lake City, Utah general goals of habilitative and rehabilitative therapies; delineating the types, Drs Houtrow and Murphy were each responsible for all aspects of conceptualizing, writing, editing, and preparing the document for locations, and benefits of therapy services; and detailing how to write publication; and both authors approved the final manuscript as a therapy prescription and include therapists in the medical home submitted. neighborhood. This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication. Pediatricians and other pediatric health care providers have a vitally important role of linking children and youth with disabilities in their Clinical reports from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external family-centered medical homes with appropriate reviewers. However, clinical reports from the American Academy of community-based services.1 Pediatric providers are often asked Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent. (frequently by families) or recognize the need to prescribe habilitative and The guidance in this report does not indicate an exclusive course of rehabilitative therapies (physical, occupational, and speech and language) treatment or serve as a standard of medical care. Variations, taking for infants, children, and youth with disabilities in their clinical practices. into account individual circumstances, may be appropriate. Many general pediatric providers describe inadequate training to All clinical reports from the American Academy of Pediatrics appropriately prescribe therapy in the various settings in which they may automatically expire 5 years after publication unless reaffirmed, – revised, or retired at or before that time. be available to children with disabilities.2 5 This clinical report will review (1) the framework of the International Classification of Functioning, DOI: https://doi.org/10.1542/peds.2019-0285 Disability and Health (ICF) for understanding the interaction between Address correspondence to Amy J. Houtrow, MD, PhD, MPH, FAAP, health conditions and personal and environmental factors that result in FAAPMR. E-mail: [email protected] disability, (2) children with disabilities and the goals of habilitation and rehabilitation services, (3) the types of therapy services available with To cite: Houtrow A, Murphy N, AAP COUNCIL ON CHILDREN their general indications, (4) the locations in which children may receive WITH DISABILITIES. Prescribing Physical, Occupational, and therapy services and potential facilitators and barriers to securing therapy Speech Therapy Services for Children With Disabilities. Pediatrics. 2019;143(4):e20190285 services, (5) the existing literature regarding the benefits of therapy and

Downloaded from www.aappublications.org/news by guest on September 27, 2021 PEDIATRICS Volume 143, number 4, April 2019:e20190285 FROM THE AMERICAN ACADEMY OF PEDIATRICS how therapy may be dosed to person-in-society level.7 The WHO physical world, such as the town optimize functional outcomes, and (6) defines impairments as “problems in where the child lives or the recommendations for writing therapy body function or structure such as topography of the community, but prescriptions. Two case examples are a significant deviation or loss,” also includes the attitudes and values provided to aid the pediatric health activity limitations as “difficulties an of the family, community, and society care provider in developing expertise individual may have in executing at large and the technologies, in addressing the therapy needs of a task,” and participation restrictions services, supports, laws, and policies children with disabilities in their as “problems an individual may where the child lives.12 Access to practices. experience in involvement in life health and therapeutic services, the situations” (Fig 1).7 physical environment, and social supports all affect how well a child ICF The ICF also includes the concepts of with disabilities functions in his or capacity and performance. Capacity is 13 The World Health Organization her daily life. the individual’s intrinsic ability to (WHO) released the ICF in 2001 perform a task or an action in as an update to the International a standardized environment, whereas CHILDHOOD DISABILITY Classification of Impairments, performance is how well the A child with a disability has an Disabilities, and Handicaps.6 The individual is able to actually perform environmentally contextualized WHO has developed 2 classification the task in his or her own real-life health-related limitation in his or her systems that can be used to describe environment.10 These concepts are existing or emerging capacity to an individual’s health at a particular important in understanding the role perform developmentally appropriate point in time. are more of habilitative and rehabilitative activities and participate, as desired, familiar with the WHO’s International therapies for children with in society.14 Childhood disability is on Classification of Diseases (ICD), disabilities, because achievement of the rise, especially for children with currently in its 10th revision, which skill requires extensive practice neurodevelopmental conditions.14–16 classifies diseases and other health and must be integrated into the A childhood disability may be related problems. Because a diagnosis alone child’s routine for the successful to congenital or acquired health often does not provide a robust enhancement of participation in conditions and may be temporary, characterization of one’s health, life events. In addition, the ICF permanent, or progressive in nature. complementing the International Classification of Diseases, 10th framework highlights the importance Common examples of health of a child’s environment on his or conditions associated with childhood Revision, is the ICF, a classification her functional outcomes.11 The disabilities that most pediatric health system with a biopsychosocial environment includes not just the care providers encounter are autism framework for describing functioning and disability associated with one’s health conditions.7

The ICF describes the relationship between health conditions diagnosed and coded in the ICD and the personal and environmental factors that act as facilitators or barriers to functioning.8 Houtrow and Zima9 provided examples of the ICF and ICD together for common pediatric diagnoses in 2017. There are 3 identified levels of functioning: the body part or organ system, the person, and the person in social situations.7 These levels correspond to body functions, activities, and participation, respectively. Disability is the umbrella term for impairments at the body FIGURE 1 part or organ system level, activity ICF. Reprinted with permission from World Health Organization. International Classification of restrictions at the person level, and Functioning, Disability and Health: Toward a Common Language for Functioning, Disability and participation restrictions at the Health. Geneva, Switzerland: World Health Organization; 2002:9.

Downloaded from www.aappublications.org/news by guest on September 27, 2021 2 FROM THE AMERICAN ACADEMY OF PEDIATRICS spectrum disorder, , TYPES OF THERAPY SERVICES are referred to as activities of daily fi , spina bi da, Although children can be supported living (daily tasks such as feeding, and acquired conditions such as by a range of therapies to address eating, dressing, or toileting) and or juvenile challenges in daily life, the 3 types of instrumental activities of daily living idiopathic . Temporary therapies detailed in this report are (complex tasks such as cooking, disability may be the result of , occupational shopping, or using a telephone). a serious illness or injury, such as therapy, and speech and language Occupational therapists are also a femur fracture. Examples of therapy. Applied behavior analysis is involved in identifying the equipment progressively disabling conditions are a therapy used frequently in autism needs a child might have to perform Duchenne and spectrum disorder and some other tasks. To address impairments in the fi cystic brosis. Disabilities may affect conditions and is discussed in great child with cerebral palsy, for example, all aspects of daily life or may affect detail in the American Academy of the works on a child only in certain settings or Pediatrics (AAP) clinical report grasping and hand coordination; to situations, such as is sometimes “Management of Children With help with an activity such as dressing, fi the case for attention-de cit/ Autism Spectrum Disorders.”19 All the occupational therapist works with hyperactivity disorder or when types of therapists are valuable the child to practice the skill and use physically exerting oneself, as in the members of the health care team and an assistive device; and to aid in case of -induced and may be involved in care delivery in participation, the occupational other pulmonary conditions. Some multiple settings across the life therapist provides strategies that the disabilities are clearly visible, and course. They have important roles in child can use in and out of the some may be less readily apparent. direct treatment but also in family classroom such as self-regulation training and advocacy.20 techniques or taking notes on a keyboard versus on paper. THERAPEUTIC GOALS Physical therapists address gross The overarching habilitation and motor skills, strength building, Speech and language pathologists, rehabilitation goals for children with endurance, and fitness. They also also called speech therapists, address 23 disabilities are to help the child focus on prevention or reduction of communication and cognition. They achieve developmentally appropriate impairments to achieve optimal work with children with disabilities functional skills, regardless of whether functional mobility and participation. to improve their expressive language these skills existed previously for the They help children move, often with skills verbally or with alternative child (rehabilitative) or are to be the use of strategies to prevent the communication techniques. To newly developed (habilitative); progression of impairments and address speech-related impairments prevent maladaptive consequences; through the use of adaptive associated with cerebral palsy, for mitigate the impact of impairments of equipment such as (braces) example, the speech therapist works the body part or structure on the and various mobility aids such as on oral motor skills to improve child’s activities and participation; walkers, , and lifts. For enunciation or teaches the child to provide adaptive strategies to a child with cerebral palsy, for use an augmentative communication minimize the impacts of functional example, the physical therapist device to successfully communicate deficits; and ensure carryover into addresses impairments related to with others and participate in social 24 other settings through family training, , weakness, poor postural interactions. Speech therapists also support, and community integration control, and lack of coordination. To evaluate and treat swallowing 17 23 strategies. Adaptive strategies can minimize activity limitations, the problems. Dysphagia is a frequently include making environmental physical therapist helps the child with occurring impairment for children modifications to accommodate the skills (among others). To with disabilities, because many child, training the child to use assistive address participation restrictions, the disabling conditions are associated technologies and other durable physical therapist helps the child with oropharyngeal or esophageal medical equipment such as walkers learn to navigate a public space such dysfunction. The workup for and wheelchairs, and helping the child as the hallways at school.21 dysphagia usually includes an develop compensatory techniques. evaluation by a speech therapist and Greater access to the physical and Pediatric occupational therapists may also include a video fluoroscopic social worlds through adaptations address upper extremity function, barium study (often referred to as provides children with disabilities fine motor skills, visual-motor a cookie swallow) or a fiber-optic 25 greater opportunities for participation function, skills, endoscopic evaluation of swallow. and connectedness with others and and the occupations or tasks that are Depending on the etiology and can enhance their well-being.18 expected of the child.22 These tasks severity of swallowing dysfunction,

Downloaded from www.aappublications.org/news by guest on September 27, 2021 PEDIATRICS Volume 143, number 4, April 2019 3 a multidisciplinary team that may targets a specific set of skills that all (inadequate coverage) as a reason for include medical and surgical of the members of the group are their children’s unmet needs.32–34 specialists such as pediatric working to achieve. Children may also When access to therapy is limited, the gastroenterologists, otolaryngologists, receive cotreatments in which more pediatric health care provider is pulmonologists, or pediatric than 1 discipline is involved in the encouraged to help coordinate rehabilitation medicine or complex therapeutic session, but no other services to the extent possible and to care physicians, along with speech children are present. make referrals to advocacy therapists and occupational organizations that can help families therapists with expertise in navigate the complex web of service disordered feeding, can create and THERAPY SETTINGS providers.35 In addition, practices execute an effective treatment plan.25 There are 4 main settings in which may find it helpful to keep a list of Some tertiary care children’s a child with a disability might need agencies and organizations to which hospitals have dedicated feeding a therapy prescription: in the to refer families handy or available on and swallowing in which hospital, in the outpatient and/or their Web site for families to access as multidisciplinary assessments with community setting, in the child’s needed. In both the inpatient and recommendation can be provided. For home, and in school. In the hospital outpatient settings, therapy services children with complex swallowing setting, the pediatric health care are based on goals for developing and feeding problems, a referral to provider directing care might order new skills, regaining lost skills (such a specialized may be an evaluation and treatments by as after an illness injury or considered. a therapist. Because the pediatric intervention), maintaining current medical home provider is usually not skills at risk for decrement, making The services provided by the 3 the inpatient attending , adaptations for functional loss(es), therapy disciplines described above communications to bridge inpatient and providing accommodations. often overlap with each other. to outpatient care plans are essential. Establishing coordinated goals can In the outpatient setting, a provider’s The third location for the provision of strengthen interdisciplinary prescription is typically needed to therapy services is in the child’s treatment synergies.26 For example, initiate an evaluation and treatment home. In-home therapies are less both physical and occupational plan by a therapist and for those common than outpatient or school- therapists address durable medical services to be covered by insurance. based therapies for older children equipment needs and help children All states have some amount of direct and youth but are frequently gain skills in transitioning from 1 access (an individual can see provided when the child with position to another. Speech and a therapist without a prescription), disabilities is young, too medically occupational therapists often most commonly for physical fragile to participate in outpatient collaborate in feeding therapy for therapy.27 Regardless of the therapies, or otherwise homebound. children with poor oral motor and prescriber of therapies, the child’s Usually, the physician documents the swallowing skills on the basis of the primary and providers medical fragility for insurance child’s needs and the expertise of the may all be involved in evaluating the companies to authorize in-home providers involved. In addition, impact of therapy on the child and therapy. One important exception is children who use augmentative participate in shared decision-making early intervention (EI) services. For communication or other assistive that involves collaborating to develop children 0 to 3 years of age, the home technologies often rely on the goals and a care plan in a mutually is the setting for EI services. Infants combined expertise of speech and respectful and trusting manner with and young children who have occupational therapists to determine the family.1 In the outpatient sector, disabilities, have developmental which devices will be most beneficial. there is variable access to pediatric delays, or are at risk because of their There are numerous other examples therapists. Children with disabilities diagnosed health conditions may be of overlap and opportunities for or developmental delays often have referred to EI for evaluation and synergies, but there is potential for unmet needs for therapy services, services under the Individuals with duplication of services and payment especially if they have inadequate Disabilities Education Act (IDEA) Part refusal by insurance companies of health insurance.28–31 Some C.36 Although processes and eligibility which pediatric health care providers insurance plans have limited vary by state, a developmental may take note. Children may also coverage for therapy services and specialist conducts a global receive therapy in a group with other may have high copays, have high evaluation of the child and provides children with 1 or more therapy coinsurance rates, or cap the number play interventions to promote disciplines involved.20 This approach, of visits per year. Many families development. On the basis of the often called group therapy, usually report a health plan problem assessment, the infant or young child

Downloaded from www.aappublications.org/news by guest on September 27, 2021 4 FROM THE AMERICAN ACADEMY OF PEDIATRICS may also receive physical, education services (through Part care system addresses many activities occupational, speech, and/or vision B).36,37 If a child needs supports or involving the hands, such as teeth therapy in the home. Providing services to participate in education in brushing; they both address fine services in the child’s natural the least restrictive environment, motor skills but with different environment has been a part of IDEA such as speech, physical, or functional tasks. Therefore, some Part C since its inception, with goals , these related children receiving school-based to enhance the development of services are covered by IDEA Part A therapies also require outpatient infants and toddlers with special and can be incorporated into the therapy services. Nonetheless, the needs and to support families to child’s individualized education therapies provided in school interact and meet the needs of their program (IEP).37 The specific frequently benefit the child outside of children.36 A key component of IDEA disabilities codified in IDEA are the school setting. Improved fine Part C EI services is an individualized mental retardation (now called motor skills for handwriting can family service plan.37 Providing intellectual disability), hearing improve the child’s ability to perform a , documenting risk impairments (including deafness), other fine motor tasks. Medical home factors and findings on physical visual impairments (including providers are encouraged to help examination, and offering an blindness), speech and language families stay abreast of school-based informed clinical opinion, as impairments, orthopedic interventions and advocate for components of the medical home, can impairments, serious emotional services when warranted. For be helpful when the child is referred disturbance, autism, traumatic brain families struggling with their school or needs to be reevaluated.36,38 The injury, other health impairments, district regarding academically value of intervening early in a child’s specific learning disabilities, deaf- necessary therapy services, a referral life is well documented39–44; blindness, and .48 to a medical legal partnership, their therefore, the pediatric provider is Because IDEA uses a categorical state’s Disability Rights Center, or encouraged to routinely evaluate definition of disability for children, another advocacy organization may development in line with AAP some disabilities are, instead, covered be warranted when other venues of recommendations, provide support to by Section 504 of the Rehabilitation advocacy have been exhausted.50 families, collaborate with Part C Act of 1973, which mandates the The pediatric health care provider programs,45,46 and advocate on behalf provision of accommodations so that may provide a child with a specific of his or her patients for services. It is children can receive their education diagnosis, but providing a diagnosis important to note that state-to-state in the least restrictive environment.37 does not necessarily mean the child variations exist because of eligibility Section 504 uses a functional will qualify for services under IDEA. criteria differences, including how descriptor, that of a limitation in For a 504 plan, the pediatric health developmental delay is defined.36 a major life area such as walking or care provider also documents the Some infants and toddlers will also speaking, instead of the IDEA medical diagnosis and, in addition, benefit from traditional outpatient categories of disabilities.37 A the associated functional limitation in therapies to supplement EI therapist may evaluate the school a major life area. Although not an services.36 These infants and toddlers environment and the needs for actual therapy prescription, pediatric frequently have complex medical accommodations for a child’s 504 medical providers may also be asked conditions or need outpatient therapy plan irrespective of whether the child to provide a recommendation about services to achieve a specific short- is placed in a regular or special 49 adaptive physical education, term goal. Occasionally, this therapy education classroom. It is notable 51 a protected right under IDEA. For may be provided to a child care that the interpretation of what more information about IDEA and center if a specialized arrangement is constitutes school-based therapy needs, please see services to promote a child’s ability to made. More information about EI the 2015 AAP clinical report “The participate academically can vary services is available in the 2013 AAP Individuals with Disabilities “ among service providers, districts, clinical report Early Intervention, Education Act (IDEA) for Children and states.49 School therapies are IDEA Part C Services, and the Medical with Special Educational Needs.”37 Home: Collaboration for Best Practice designed to promote attainment of and Best Outcomes.”36 a student’s educational goals and are Regardless of the type of therapy or often more narrowly focused than the setting in which it is delivered, The fourth setting for a child with outpatient, medically based therapies. therapists are key members of the a disability to receive therapies is the For example, an occupational medical home neighborhood. school. IDEA,47 passed in 1975, therapist in the school may work on Strategies for communication are legislates federal funding to states for handwriting, whereas an required to optimize service EI (through Part C) and special occupational therapist in the health coordination and ensure that children

Downloaded from www.aappublications.org/news by guest on September 27, 2021 PEDIATRICS Volume 143, number 4, April 2019 5 are receiving all aspects of the therapy are clearly delineated and review the evidence and engage in medical home.52 This effort is measureable,65,66 and goal setting is a dialogue with families about the especially challenging for children a central feature of rehabilitation.67 goals of treatment and how best to with disabilities who often require For sustained positive benefits from achieve them.82 Other treatments and extensive care coordination for therapeutic interventions, activities techniques are a part of a standard of numerous specialty services and thus can be practiced in the child’s care not subject to randomized are less likely to receive care in environment and reinforced by the controlled trials, but newer a medical home.28 parents or other caregivers.2 Practice treatments and techniques require in one’s natural environment is more rigorous research before essential for success; therefore, conclusions can be drawn about their THERAPEUTIC BENEFITS parents and/or caregivers are efficacy.83–85 Referrals to specialists The efficacy of therapy services to encouraged to practice skill building with expertise in the various help children gain and/or maintain outside of the therapeutic setting. therapeutic modalities and function and provide adaptations is When a therapeutic intervention is treatments may be considered by well documented.53–58 Provision of directed at 1 domain of functioning medical home providers to help a home program with caregiver (body structures and function, determine which therapeutic training and support is generally activities, or participation) there can interventions to prescribe. Pediatric “ ” indicated, because carryover of be a ripple effect of positive rehabilitation medicine physicians 13,53,68 skills is enhanced by frequent outcomes in other domains. (also known as pediatric repetition.59–61 To routinely perform For example, strengthening the legs physiatrists), neurodevelopmental newly achieved skills, children need can lead to improved walking, which pediatricians, and developmental and practice in their own environment; can also be associated with improved behavioral pediatricians are well having the capacity to perform a task ability to navigate and participate in versed in the therapeutic options that in a structured environment can the classroom. Taking a holistic may not be standard but have fi 86–95 improve performance but is not approach has clear value and is evidence for ef cacy. These enough to demonstrate achievement associated with improved therapy specialists tend to be strong medical 55,69–72 of a therapeutic goal.13 Children outcomes. home neighbors because of their need to demonstrate that they can expertise in coordinating care for Although the evidence base for the routinely perform the activity in the children with disabilities across effectiveness of various therapies is face of challenges that exist in their settings. In some cases, they may be increasing, not all therapeutic environments for successful transfer or may become the medical home modalities and techniques have been of skills.62 A home program can provider if the family can easily shown to be efficacious, and some further enhance a child’s access their services and other have harmful adverse effects and are participation in other structured criteria of the medical home can be therefore not promoted in lieu of activities that incorporate functional met by their practices. Various forms standard or evidence-based of shared management may be skills such as dance classes, karate, or 73–79 school that are appropriately therapies. For example, explored by the primary care adapted for the child with disabilities. hyperbaric oxygen for the treatment physician and the specialists to The time spent practicing activities of cerebral palsy has not been shown ensure children with disabilities are fi with real-world carryover is part of to be ef cacious and is associated receiving optimal care. with harmful adverse effects and is the critical link between building 78,80,81 capacity and performance.13 An therefore not recommended. Similarly, evidence for the benefits of THERAPY DOSING important role of pediatric providers 81 in optimizing the function of children patterning is lacking. Treatment Determining the appropriate dose of with disabilities is advocating with success that is only supported by case therapy (how much therapy, how families for in activities that reports or anecdotal data and not by often, and for how long) remains 13,22,57 best support participation in life carefully designed research studies elusive and largely subjective. events. The pediatric health care warrants further investigation and Dose is determined by the minutes provider is an ideal advocate for early discussion before prescribing. each therapy session is, how often it involvement because of the critical Families often seek complementary is provided, and for how long (weeks, early childhood period for or alternative treatments and may ask months, years). Although much neuroplasticity.63,64 their pediatric health provider to research is being conducted, there is advocate for these treatments on not yet a strong evidence base to Functional improvements are more behalf of the child. In these support any particular dosing likely to occur when the goals of circumstances, it is important to strategy for specific disabilities or

Downloaded from www.aappublications.org/news by guest on September 27, 2021 6 FROM THE AMERICAN ACADEMY OF PEDIATRICS conditions,22 except in unilateral therapy services.99 This is especially who can work with the family to hemiplegic cerebral palsy, for which true of older children who may have develop a goal-directed plan of high-intensity upper extremity already met most of their care that addresses concerns, such therapy that is activity-based has developmental milestones. Children as lack of measurable progress but been shown to improve outcomes to with disabilities who use adaptive the need for prevention of further a greater degree than standard equipment well may only need to be impairment, on which all members therapy administration (such as once checked on periodically, and when of the team (including family) a week).96 Because of their attention new equipment is ordered, they may agree. spans, young children usually do well need a short course of more intense with shorter duration of therapy per therapy for training with the new 21 session and, therefore, may need device. The process of therapeutic THE THERAPY PRESCRIPTION more total sessions or breaks within surveillance is especially important, sessions. Children with temporary because children with disabilities are When a child with functional disabilities may need short-term at risk for skill regression or lack of limitations needs therapy or when therapy to make adaptations to their progress because of changes in their there is concern for developmental condition and recover from it. health or changes in their delay, before writing a therapy Children with new-onset disabilities, environments. Reengaging therapy prescription, it is helpful to review such as from traumatic injuries, services quickly can help mitigate past and current therapy reports (if fi frequently need intense therapy deterioration in participation and any exist), family-identi ed concerns, fi services shortly after injury often in quality of life. Similarly, a child on and any ndings on developmental an inpatient setting with coordinated a long-term therapeutic treatment screening or testing in addition to the medical and care and then therapy program may need to have goals of therapy and the expected require ongoing therapy on a less services increased when a new outcomes. When prescribing initial or intense schedule to optimize their problem occurs or a goal is identified continuing therapy services, the outcomes.97 Children with disabilities on the basis of a change in functional provider is advised to identify the associated with chronic health status or developmental therapy discipline; the medical conditions often need therapy on an expectation.21 This sudden change in condition associated with the ongoing basis with variable therapy needs is often referred to as disability (or the constellation of intensities on the basis of their a burst or an episode of therapy. For symptoms and findings if the individual functional goals. example, intense may be diagnosis is unknown), which prescribed when a child is just on the indicates the medical necessity of Therapies can be dosed in an intense cusp of developing walking skills or the treatment; any precautions or fashion, such as 45 to 60 minutes 2 or to incorporate efficient gait skills restrictions; the goals of therapy; and more times a week, especially when when gait deviations are present. the frequency and duration of a short-term goal is identified and Strong collaboration between the treatment. Additionally, the deemed quickly achievable.21 family, the treating therapists, prescription may include the specific Similarly, after a medical event or specialists, and the pediatric medical type or modality of therapy, if 1 is a , some children with home provider helps identify the best desired (Fig 2). If the child recently disabilities need intense therapy to dosing strategies that consider the hadsurgeryandisinneedofshort- regain temporarily lost function and child’s health, current functional term therapy or is restricted from then can return to their regular status, goals, readiness for therapy, his or her usual therapy routine, the therapy schedule. A commonly response to intervention, and surgeon is often the provider who delivered dose of therapy is for 30 to cessation of services, if writes these prescriptions and 60 minutes per week for an episode warranted.21,22,100 Pediatric manages restrictions such as weight- of care, such as during the entire providers may receive requests from bearing precautions. After school year in the case of school- families for therapies that are not evaluation by the therapist, the based therapies.98 This schedule is warranted. In these situations, provider may be asked to revise the often used when a child exhibits family-centered, shared decision- therapyprescriptiononthebasisof continued progress toward goals and making techniques may be used to the recommendations of the is at risk for a lack of progress or establish goals, and then strategies therapist who participates in the regression if therapy services were to achieve these goals can be development of goals and the halted.21 Children who are identified.1,101 One potential strategy treatment plan. See the cases in Text functionally stable and have attained is to make a referral to a specialist Boxes 1 and 2 for examples of their current functional goals may with expertise in the evidence therapy prescriptions and the only need periodic or intermittent base for therapeutic interventions elements of a therapy report.

Downloaded from www.aappublications.org/news by guest on September 27, 2021 PEDIATRICS Volume 143, number 4, April 2019 7 coverage of therapy services from insurance companies. When addressing a denial, either over the phone or in writing, it behooves the provider to have some key pieces of information available to explain why the prescribed service is medically necessary: the diagnosis or diagnoses for which the service is needed, what the service is expected to accomplish (ie, how the service is reasonably likely to address the disabling condition), that there is not an equally effective less costly option, and other pertinent . Pediatric health care providers may also want to familiarize themselves with the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) FIGURE 2 standards, because a majority of Sample therapy prescription. DOB, date of birth. children with long-term disabilities are covered by Medicaid.28,103,104 The EPSDT amendments to Medicaid direct coverage of “early and Providing a high level of detail in members of the medical home periodic” screening and diagnostic a therapy prescription may be beyond neighborhood and can help advance services to identify defects and the expertise of many pediatric the care goals set in the child’scare chronic conditions in addition to providers. Nonetheless, providing plan with their medical home. providing coverage of health care and a clear prescription to help guide the Pediatric providers are encouraged, treatments to “correct or ameliorate” therapy is important. Because there is nonetheless, to initiate the process such conditions and defects.104 This a general lack of evidence for the for such therapies, because access to encompasses treatments that dosing of therapy, providers are a specialist may be challenging, and improve health outcomes as well as encouraged to consider the amount of the value of early engagement treatments that enable children with functional improvement anticipated, with therapies is well documented. disabilities to achieve and maintain the urgency of the need for the skill Major professional organizations, function.104 Specifically, physical, development, and how quickly the existing federal guidelines, and third- occupational, and/or speech therapy child is gaining skills. Information party payers all emphasize the are mandated pursuant to 42 US Code about the trajectory of disability important role of physicians in 1396d(a)(7) and/or 1396d(a)(11). As associated with the condition, the determining the medical necessity a result, coverage for therapy services evidence of the value of therapies to for and ordering of services.2 The is frequently better under Medicaid improve functioning, and how the choice to refer may also be affected than under commercial insurance individual child is expected to by the severity and complexity of the plans that limit treatments.103 For benefit from the interventions is also child’s disabilities, the family’s additional reading on EPSDT, please important when providing written desires, the availability of qualified see “EPSDT - A Guide for States: medical justification. Providers who specialists in the community or Coverage in the Medicaid Benefit for prefer not to write detailed therapy region, and the local or regional Children and Adolescents” (https:// prescriptions can consult with variations of how therapies are www.medicaid.gov/medicaid/ pediatric rehabilitation medicine delivered. Pediatric medical home benefits/downloads/epsdt_coverage_ physicians, neurodevelopmental providers remain the locus of guide.pdf). pediatricians, developmental and communication and coordination behavioral pediatricians, and other of services.35 Beyond the Therapy Prescription specialists, including physical, The primary care medical home occupational, and speech therapists Dealing With Insurance Denials engages in the coordination of in their medical community. These The pediatric health care provider is services for children with disabilities types of providers can be valuable likely all too familiar with denials for in school, hospital, and community

Downloaded from www.aappublications.org/news by guest on September 27, 2021 8 FROM THE AMERICAN ACADEMY OF PEDIATRICS BOX 1 CASE EXAMPLE OF A CHILD WITH CEREBRAL PALSY Liam is an 11-year-old boy with spastic , a type of cerebral palsy that mainly affects the lower extremities, who has recently moved with his family from another state and is establishing care in your primary care practice. He wears braces on his lower legs and uses forearm to walk, although he can walk short distances without his crutches at home. He is in the fifth grade and rides the bus with his older sister, who makes sure he gets on and off the bus safely, because he is a little impulsive and falls frequently. His mom performs his lower body dressing for him because they are often in a rush in the mornings before school. She reports that he could do all of his dressing except getting his shoes on over his braces if he had to. At school, he placed in the advanced reading group but struggles with visual perceptual tasks and has “terrible handwriting,” according to his mother. The IEP meeting is next week, and prescriptions are requested by the school. The mom also wants to get him involved in therapies outside of school. Before they moved, he received physical therapy once a week and occupational therapy twice a month. Liam has several therapeutic needs. The most pressing issue is his IEP. On the prescription for therapies at school, you document his diagnosis (spastic diplegic cerebral palsy) and the types of therapies to be provided at school (physical and occupational), the reasons he needs these therapies (mobility, safety, fine motor skills, and visual perceptual skills), the duration of therapy (entire school year), and the frequency (1–2 times per week). You also write a prescription for adaptive physical education so that the school’s physical therapist can work with the gym teacher to create a safe and inclusive program for him. To address Liam’s outpatient therapy needs, you prescribe the following:

1. Physical therapy: evaluation and treatment of spastic diplegia, duration 6 months, frequency 1 to 2 times per week to address , ambulation longer distances with Lofstrand crutches and gross motor skills, safety awareness (especially for getting on and off the school bus), equipment needs, for spasticity management, and family training for carryover in the home environment. No restrictions. 2. Occupational therapy: evaluation and treatment of spastic diplegia, duration 6 months, frequency 1 to 2 times per week to address fine motor skills, activities of daily living (especially dressing), safety awareness, visual perceptual skills, and family training for carryover in the home environment. No restrictions. After Liam’s evaluations by the physical and occupational therapists, you receive a letter from each of them with information about the evaluations, the goals that were set, and some changes that they request. Specifically, the physical therapist thinks that Liam’s is really impairing his progress toward ambulation without crutches. She recommends doing once-a-week hippotherapy to strengthen his core and improve his balance and would like for you to write the prescription. The occupational therapists noted that like many children with spastic diplegia, Liam has poor fine motor skills, which have really impacted his handwriting. She recommends an intense handwriting group therapy program that meets 3 afternoons a week for 2 months. She needs a special prescription for this program. After discussing the recommendations with Liam’s mother, you write the prescriptions and await feedback. A few weeks later, your nurse manager reports that the hippotherapy you prescribed has been denied by Liam’s insurance. The nurse shares the draft of the letter of medical justification to which you add the evidence in support of the use of hippotherapy in children with cerebral palsy and reiterate the specific goals (core strengthening and balance) along with the intended outcome of improved ambulation without an assistive device.102 The denial is overturned. Three months later, you receive interim therapy reports from Liam’s outpatient physical and occupational therapists. Each of these reports details the initial skill level Liam had when he started therapy, the specific goals they set with Liam and his mother, his achievements and his current status with a recommendation to continue the services to address existing and newly developed goals. The occupational therapist spoke to his physical therapist about shoes that would be easier for Liam to don over his orthotics because he had not been successful at achieving his lower body dressing goal with occupational therapy. The physical therapist sent a fax to your office requesting a prescription for orthotic-containing shoes. At Liam’s follow-up visit, his mom indicates that she is so proud of him that he can stand without holding on to anything for nearly 1 minute and that he can get himself dressed in the morning if she makes sure he has enough time before the bus comes. She also reports that it seems easier for him to make friends because he can usually keep up with other kids if activities are modified. You agree that he seems to be making great progress, as also documented in summary reports from his therapists.

settings.35 Regular communication and family functioning and concerns. provider may need to alert the between the child’s care team This is especially important when therapist(s) and delineate new (parents and/or caregivers, children receive services in multiple precautions or goals. When educators, therapists, subspecialists, settings simultaneously from multiple a therapist notes a functional decline and medical home providers) providers or have other that is unanticipated, he or she can includes updates on the child’s vulnerabilities such as being in foster refer back to the pediatric health functional status, the achievement of care. In addition, when the child’s care provider who is able to therapy goals, identification of new medical or functional status changes evaluate the child and seek to goals, the planned cessation of or when other circumstances warrant determine the etiology for the decline therapy services when appropriate, a change in treatment, the prescribing and discuss findings with the family.

Downloaded from www.aappublications.org/news by guest on September 27, 2021 PEDIATRICS Volume 143, number 4, April 2019 9 BOX 2 CASE EXAMPLE OF A CHILD WITH LANGUAGE DELAY Sophia is a 2-year-old who was born at 32 weeks’ gestation who has yet to say any words. At an ill visit for diarrhea, Sophia’s mother shares her worries about her lack of expressive communication. You reviewed her history, which included a normal hearing screen in the NICU, no concerns on her 9-month well-child visit, and no 18-month developmental surveillance because the family had moved away and then returned to your practice. You conduct an examination that reveals that Sophia responds to her name and other noises, is happy and playful, seems to understand information and can follow commands, has normal gross motor and fine motor skills, and babbles, but mostly communicates by pointing and gesturing. After confirming normal hearing on examination, you diagnose Sophia with an isolated speech delay. You refer the family to EI services and also to outpatient speech therapy. In your prescription for outpatient speech therapy, you write her diagnosis as developmental disorder of speech and language and request therapy 2 to 3 times per week, 30 minutes per session for 12 weeks to address her expressive communication skills. At reevaluation 3 months later, Sophia’s expressive speech is much improved. EI services are once a week, and the outpatient speech therapist recommends decreasing the frequency of speech therapy to once a week, because most of her goals have been met. You write a new prescription for ongoing outpatient speech therapy on the basis of the recommendations of the speech therapist and your discussion with Sophia’s mother. At Sophia’s 3-year well-child visit, Sophia’s mother reports that EI services stopped a few months ago and that the outpatient speech therapist had tested Sophia and that her expressive language skills were in the low-normal range. Her mother reports that she speaks spontaneously with other children during play and is able to “get her point across” with adults using words. In reviewing the report from the speech therapist, you agree that services are no longer warranted, but Sophia’s mother wants her to continue to get speech therapy until she tests into the midnormal range. You recognize that ongoing speech therapy services are not medically justified, so you engage in a shared decision-making process to implement a home program for continued skill development and practice, an approach to monitoring of Sophia’s language skills and development closely, and a formal evaluation of her communication skills when entering school or sooner, should there be any concerns regarding her development.

Coordinating care that is organized Garey H. Noritz, MD, FAAP STAFF Christopher J. Stille, MD, MPH, FAAP around patient- and family-centered Alex Kuznetsov, RD goals with clear communication Larry Yin, MD, MSPH, FAAP between the health care team members is the goal to help ABBREVIATIONS optimize the health, function, and FORMER COUNCIL ON CHILDREN WITH well-being of children with DISABILITIES EXECUTIVE COMMITTEE AAP: American Academy of disabilities. MEMBERS Pediatrics Amy J. Houtrow, MD, PhD, MPH, FAAP EI: early intervention Nancy Murphy, MD, FAAP EPSDT: Early and Periodic LEAD AUTHORS Kenneth W. Norwood, Jr, MD, FAAP, Screening, Diagnosis, and Amy J. Houtrow, MD, PhD, MPH, FAAP Immediate Past Chairperson Treatment Nancy A. Murphy, MD, FAAP ICD: International Classification of Diseases COUNCIL ON CHILDREN WITH DISABILITIES LIAISONS ICF: International Classification of EXECUTIVE COMMITTEE, 2017–2018 Peter J. Smith, MD, MA, FAAP – Section on Functioning, Disability and Dennis Z. Kuo, MD, MHS, FAAP, Chairperson Developmental and Behavioral Pediatrics Health Susan Apkon, MD, FAAP Edwin Simpser, MD, FAAP – Section on IDEA: Individuals with Disabilities Timothy J. Brei, MD, FAAP Home Care Education Act – Centers Lynn F. Davidson, MD, FAAP Georgina Peacock, MD, MPH, FAAP IEP: individualized education Beth Ellen Davis, MD, MPH, FAAP for Disease Control and Prevention Kathryn A. Ellerbeck, MD, FAAP Marie Y. Mann, MD, MPH, FAAP – Maternal program Susan L. Hyman, MD, FAAP and Child Health Bureau WHO: World Health Organization Mary O’Connor Leppert, MD, FAAP Cara Coleman, JD, MPH – Family Voices

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2019 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose. FUNDING: No external funding. POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

Downloaded from www.aappublications.org/news by guest on September 27, 2021 10 FROM THE AMERICAN ACADEMY OF PEDIATRICS REFERENCES 1. Murphy NA, Carbone PS; Council on context of disability. Disabil Health J. with disabilities. J Fam Health Care. Children With Disabilities; American 2017;10(4):461–466 2003;13(2):38–40 Academy of Pediatrics. Parent- 10. Almansa J, Ayuso-Mateos JL, Garin O, 21. Section on Pediatrics American provider-community partnerships: et al; MHADIE Consortium. The Physical Therapy Association. Dosing optimizing outcomes for children with International classification of Considerations: Recommending School- disabilities. Pediatrics. 2011;128(4): functioning, disability and health: Based Physical Therapy Interventions 795–802 development of capacity and Under IDEA Resource Manual. 2. Sneed RC, May WL, Stencel C. Policy performance scales. J Clin Epidemiol. Alexandria, VA: Subcommittee on versus practice: comparison of 2011;64(12):1400–1411 Dosing; 2014 prescribing therapy and durable 11. Lollar DJ, Simeonsson RJ. Diagnosis to 22. Gee BM, Lloyd K, Devine N, et al. Dosage medical equipment in medical and function: classification for children and parameters in pediatric outcome educational settings. Pediatrics. 2004; youths. J Dev Behav Pediatr. 2005;26(4): studies reported in 9 peer-reviewed 114(5). Available at: www.pediatrics. 323–330 occupational therapy journals from org/cgi/content/full/114/5/e612 2008 to 2014: a content analysis. 12. Schneidert M, Hurst R, Miller J, Ustün B. Rehabil Res Pract. 2016;2016:3580789 3. Shah RP, Kunnavakkam R, Msall ME. The role of environment in the ’ Pediatricians knowledge, attitudes, International Classification of 23. American Speech Language Hearing and practice patterns regarding Functioning, Disability and Health (ICF). Association. ASHA practice policy: special education and individualized Disabil Rehabil. 2003;25(11–12):588–595 of practice in speech-language education programs. Acad Pediatr. . 2016. Available at: www.asha. 2013;13(5):430–435 13. Gannotti ME, Christy JB, Heathcock JC, org/policy/SP2016-00343/. Accessed Kolobe TH. A path model for evaluating September 6, 2016 4. Sneed RC, May WL, Stencel CS. Training dosing parameters for children with 24. Desch LW, Gaebler-Spira D; Council on of pediatricians in care of physical cerebral palsy. Phys Ther. 2014;94(3): Children With Disabilities. Prescribing disabilities in children with special 411–421 health needs: results of a two-state assistive-technology systems: focus on of practicing pediatricians and 14. Halfon N, Houtrow A, Larson K, children with impaired communication. national resident training programs. Newacheck PW. The changing landscape Pediatrics. 2008;121(6):1271–1280 of disability in childhood. Future Child. Pediatrics. 2000;105(3, pt 1): 25. Mezoff EA. Focus on diagnosis: 2012;22(1):13–42 554–561 dysphagia. Pediatr Rev. 2012;33(11): – 5. Symons AB, McGuigan D, Akl EA. A 15. Houtrow AJ, Larson K, Olson LM, 518 520 curriculum to teach medical students Newacheck PW, Halfon N. Changing 26. Palisano RJ, Begnoche DM, Chiarello LA, to care for people with disabilities: trends of childhood disability, 2001- Bartlett DJ, McCoy SW, Chang HJ. – development and initial 2011. Pediatrics. 2014;134(3):530 538 Amount and focus of physical therapy implementation. BMC Med Educ. 2009; 16. Boyle CA, Boulet S, Schieve LA, et al. and occupational therapy for young 9:78 Trends in the prevalence of children with cerebral palsy. Phys Occup Ther Pediatr. 2012;32(4):368–382 6. Dahl TH. International classification of developmental disabilities in US functioning, disability and health: an children, 1997-2008. Pediatrics. 2011; 27. American Physical Therapy Association. – introduction and discussion of its 127(6):1034 1042 Levels of patient access to physical potential impact on rehabilitation 17. Palisano RJ, Chiarello LA, King GA, Novak therapist services in the states. 2016. services and research. J Rehabil Med. I, Stoner T, Fiss A. Participation-based Available at: http://www.apta.org/ 2002;34(5):201–204 therapy for children with physical uploadedFiles/APTAorg/Advocacy/State/ disabilities. Disabil Rehabil. 2012; Issues/Direct_Access/ 7. World Health Organization. DirectAccessbyState.pdf. Accessed fi 34(12):1041–1052 International Classi cation of September 6, 2016 Functioning, Disability and Health: 18. Stineman MG, Streim JE. The biopsycho- Toward a Common Language for ecological paradigm: a foundational 28. Houtrow AJ, Okumura MJ, Hilton JF, fi Functioning, Disability and Health. theory for medicine. PM R. 2010;2(11): Rehm RS. Pro ling health and health- Geneva, Switzerland: World Health 1035–1045 related services for children with Organization; 2002 special health care needs with and 19. Myers SM, Johnson CP; American without disabilities. Acad Pediatr. 2011; 8. Cieza A, Brockow T, Ewert T, et al. Academy of Pediatrics Council on 11(6):508–516 Linking health-status measurements Children With Disabilities. Management 29. Magnusson D, Palta M, McManus B, to the international classification of of children with autism spectrum Benedict RE, Durkin MS. Capturing functioning, disability and health. disorders. Pediatrics. 2007;120(5): unmet therapy need among young J Rehabil Med. 2002;34(5):205–210 1162–1182 children with developmental delay 9. Houtrow AJ, Zima BT. Framing 20. Hong CS, Palmer K. Occupational using national survey data. Acad childhood mental disorders within the therapy and physiotherapy for children Pediatr. 2016;16(2):145–153

Downloaded from www.aappublications.org/news by guest on September 27, 2021 PEDIATRICS Volume 143, number 4, April 2019 11 30. McManus BM, Prosser LA, Gannotti ME. two years of life. Res Dev Disabil. 2014; Pediatrics. 2013;131(6). Available at: Which children are not getting their 35(1):117–126 www.pediatrics.org/cgi/content/full/ needs for therapy or mobility aids met? 39. McCormick MC, Brooks-Gunn J, Buka SL, 131/6/e2016 Data from the 2009-2010 National et al. Early intervention in low birth 47. Individuals with Disabilities Education Survey of Children with Special Health weight premature infants: results at Act. Statute and regulations. Available Care Needs. Phys Ther. 2016;96(2): 18 years of age for the Infant Health at: https://sites.ed.gov/idea/ – 222 231 and Development Program. Pediatrics. statuteregulations/. Accessed January 31. Miller AR, Armstrong RW, Mâsse LC, 2006;117(3):771–780 7, 2018 Klassen AF, Shen J, O’Donnell ME. 40. SP, Chang SM, Vera-Hernández 48. Aron L, Loprest P. Disability and the Waiting for child developmental and M, Grantham-McGregor S. Early education system. Future Child. 2012; rehabilitation services: an overview of childhood stimulation benefits adult 22(1):97–122 issues and needs. Dev Med Child competence and reduces violent – 49. Cartwright JD; American Academy of Neurol. 2008;50(11):815 821 behavior. Pediatrics. 2011;127(5): Pediatrics Council on Children With 32. Kogan MD, Newacheck PW, Honberg L, 849–857 Disabilities. Provision of educationally Strickland B. Association between 41. Reynolds AJ, Temple JA, Robertson DL, related services for children and underinsurance and access to care Mann EA. Long-term effects of an early adolescents with chronic diseases and among children with special health childhood intervention on educational disabling conditions. Pediatrics. 2007; care needs in the . achievement and juvenile arrest: a 15- 119(6):1218–1223 – Pediatrics. 2005;116(5):1162 1169 year follow-up of low-income children 50. Zuckerman B, Sandel M, Smith L, 33. Kogan MD, Newacheck PW, Blumberg in public schools. JAMA. 2001;285(18): Lawton E. Why pediatricians need SJ, et al. Underinsurance among 2339–2346 lawyers to keep children healthy. children in the United States. N Engl 42. Park HY, Maitra K, Achon J, Loyola E, – – Pediatrics. 2004;114(1):224 228 J Med. 2010;363(9):841 851 Rincón M. Effects of early intervention 51. Murphy NA, Carbone PS; American 34. Huang ZJ, Kogan MD, Yu SM, Strickland on mental or neuromusculoskeletal and Academy of Pediatrics Council on B. Delayed or forgone care among movement-related functions in children Children With Disabilities. Promoting children with special health care needs: born low birthweight or preterm: the participation of children with an analysis of the 2001 National Survey a meta-analysis. Am J Occup Ther. 2014; disabilities in sports, recreation, and of Children with Special Health Care 68(3):268–276 physical activities. Pediatrics. 2008; Needs. Ambul Pediatr. 2005;5(1):60–67 43. Khetani M, Graham JE, Alvord C. 121(5):1057–1061 35. Council on Children with Disabilities Community participation patterns 52. McAllister JW, Presler E, Cooley WC. and Medical Home Implementation among preschool-aged children who Practice-based care coordination: Project Advisory Committee. Patient- have received Part C early intervention a medical home essential. Pediatrics. and family-centered care coordination: services. Child Care Health Dev. 2013; 2007;120(3). Available at: www. a framework for integrating care for 39(4):490–499 pediatrics.org/cgi/content/full/120/3/ children and youth across multiple 44. Kingsley K, Mailloux Z. Evidence for the e723 systems. Pediatrics. 2014;133(5). effectiveness of different service 53. Park EY, Kim WH. Meta-analysis of the Available at: www.pediatrics.org/cgi/ delivery models in early intervention effect of strengthening interventions in content/full/133/5/e1451 services. Am J Occup Ther. 2013;67(4): individuals with cerebral palsy. Res Dev 36. Adams RC, Tapia C; Council on Children 431–436 Disabil. 2014;35(2):239–249 with Disabilities. Early intervention, 45. Council on Children With Disabilities; 54. Dewar R, Love S, Johnston LM. Exercise IDEA Part C services, and the medical Section on Developmental Behavioral interventions improve postural control home: collaboration for best practice Pediatrics; Bright Futures Steering in children with cerebral palsy: and best outcomes. Pediatrics. 2013; Committee; Medical Home Initiatives for a systematic review. Dev Med Child 132(4). Available at: www.pediatrics. Children With Project Neurol. 2015;57(6):504–520 org/cgi/content/full/132/4/e1073 Advisory Committee. Identifying infants 37. Lipkin PH, Okamoto J; Council on and young children with developmental 55. Case-Smith J, Frolek Clark GJ, Children with Disabilities; Council on disorders in the medical home: an Schlabach TL. Systematic review of School Health. The Individuals With algorithm for developmental interventions used in occupational Disabilities Education Act (IDEA) for surveillance and screening [published therapy to promote motor performance children with special educational correction appears in Pediatrics. 2006; for children ages birth-5 years. Am needs. Pediatrics. 2015;136(6). Available 118(4):1808–1809]. Pediatrics. 2006; J Occup Ther. 2013;67(4):413–424 – at: www.pediatrics.org/cgi/content/full/ 118(1):405 420 56. Chen YN, Liao SF, Su LF, Huang HY, Lin 136/6/e1650 46. Noritz GH, Murphy NA; Neuromotor CC, Wei TS. The effect of long-term 38. Lobo MA, Paul DA, Mackley A, Maher J, Screening Expert Panel. Motor delays: conventional physical therapy and Galloway JC. Instability of delay early identification and evaluation independent predictive factors analysis classification and determination of [published correction appears in in children with cerebral palsy. Dev early intervention eligibility in the first Pediatrics. 2017;140(3):e20172081]. Neurorehabil. 2013;16(5):357–362

Downloaded from www.aappublications.org/news by guest on September 27, 2021 12 FROM THE AMERICAN ACADEMY OF PEDIATRICS 57. Franki I, Desloovere K, De Cat J, et al. improvements in impairments, activity children with cerebral palsy. Pediatr The evidence-base for basic physical and participation in children with Phys Ther. 2011;23(2):136–142 therapy techniques targeting lower developmental coordination disorder. 76. Lacey DJ, Stolfi A, Pilati LE. Effects of limb function in children with cerebral Disabil Rehabil. 2016;38(10):979–986 hyperbaric oxygen on motor function in palsy: a systematic review using the 67. Wade DT. Goal setting in rehabilitation: children with cerebral palsy. Ann International Classification of an overview of what, why and how. Clin Neurol. 2012;72(5):695–703 Functioning, Disability and Health as Rehabil. 2009;23(4):291–295 a conceptual framework. J Rehabil 77. Novak I, Badawi N. Last breath: Med. 2012;44(5):385–395 68. Sakzewski L, Carlon S, Shields N, Ziviani effectiveness of hyperbaric oxygen treatment for cerebral palsy. Ann 58. Law MC, Darrah J, Pollock N, et al. Focus J, Ware RS, Boyd RN. Impact of intensive Neurol. 2012;72(5):633–634 on function: a cluster, randomized upper limb rehabilitation on quality of controlled trial comparing child- versus life: a randomized trial in children with 78. Goldfarb C, Genore L, Hunt C, et al. context-focused intervention for young unilateral cerebral palsy. Dev Med Child Hyperbaric oxygen therapy for the – children with cerebral palsy. Dev Med Neurol. 2012;54(5):415 423 treatment of children and youth with Child Neurol. 2011;53(7):621–629 69. Kreider CM, Bendixen RM, Huang YY, Lim autism spectrum disorders: an evidence-based systematic review. Res 59. Novak I, Cusick A, Lannin N. Y. Review of occupational therapy Autism Spectr Disord. 2016;29–30:1–7 Occupational therapy home programs intervention research in the practice for cerebral palsy: double-blind, area of children and youth 2009-2013. 79. Weitlauf AS, Sathe N, McPheeters ML, randomized, controlled trial. Pediatrics. Am J Occup Ther. 2014;68(2):e61–e73 Warren ZE. Interventions targeting 2009;124(4). Available at: www. 70. Case-Smith J. Systematic review of sensory challenges in autism spectrum pediatrics.org/cgi/content/full/124/4/ interventions to promote social- disorder: a systematic review. e606 emotional development in young Pediatrics. 2017;139(6):e20170347 60. Novak I, McIntyre S, Morgan C, et al. A children with or at risk for disability. 80. McDonagh MS, Morgan D, Carson S, systematic review of interventions for Am J Occup Ther. 2013;67(4):395–404 Russman BS. Systematic review of children with cerebral palsy: state of hyperbaric oxygen therapy for cerebral 71. Morgan C, Novak I, Badawi N. Enriched the evidence. Dev Med Child Neurol. palsy: the state of the evidence. Dev environments and motor outcomes in 2013;55(10):885–910 Med Child Neurol. 2007;49(12):942–947 cerebral palsy: systematic review and 61. McIntyre LL. Parent training for young meta-analysis. Pediatrics. 2013;132(3). 81. Collet JP, Vanasse M, Marois P, et al; children with developmental Available at: www.pediatrics.org/cgi/ HBO-CP Research Group. Hyperbaric disabilities: randomized controlled trial. content/full/132/3/e735 oxygen for children with cerebral palsy: Am J Ment Retard. 2008;113(5):356–368 a randomised multicentre trial. Lancet. 72. Gillett J. The Pediatric Acquired Brain 2001;357(9256):582–586 62. Taub E, Uswatte G. Importance for CP Injury Community Outreach Program rehabilitation of transfer of motor (PABICOP) - an innovative 82. McClafferty H, Vohra S, Bailey M, et al; improvement to everyday life. comprehensive model of care for Section on Integrative Medicine. Pediatrics. 2014;133(1). Available at: children and youth with an acquired Pediatric integrative medicine. www.pediatrics.org/cgi/content/full/ brain injury. NeuroRehabilitation. 2004; Pediatrics. 2017;140(3):e20171961 – 133/1/e215 19(3):207 218 83. Meyer-Heim A, van Hedel HJ. Robot- 63. Basu AP. Early intervention after 73. Ziring PR, Brazdziunas D, Cooley WC; assisted and computer-enhanced perinatal : opportunities and American Academy of Pediatrics; therapies for children with cerebral challenges. Dev Med Child Neurol. 2014; Committee on Children with Disabilities. palsy: current state and clinical 56(6):516–521 The treatment of neurologically implementation. Semin Pediatr Neurol. 2013;20(2):139–145 64. Yang JF, Livingstone D, Brunton K, et al. impaired children using patterning. Training to enhance walking in children Pediatrics. 1999;104(5, pt 1):1149–1151. 84. Case-Smith J, Weaver LL, Fristad MA. A with cerebral palsy: are we missing the Reaffirmed May 2018 systematic review of sensory window of opportunity? Semin Pediatr 74. Zimmer M, Desch L; Section On processing interventions for children – Neurol. 2013;20(2):106 115 Complementary And Integrative with autism spectrum disorders. Autism. 2015;19(2):133–148 65. Bower E, McLellan DL, Arney J, Campbell Medicine; Council on Children with MJ. A randomised controlled trial of Disabilities; American Academy of 85. Fasoli SE, Ladenheim B, Mast J, Krebs different intensities of physiotherapy Pediatrics. Sensory integration HI. New horizons for robot-assisted and different goal-setting procedures in therapies for children with therapy in pediatrics. Am J Phys Med 44 children with cerebral palsy. Dev developmental and behavioral Rehabil. 2012;91(11, suppl 3):S280–S289 Med Child Neurol. 1996;38(3):226–237 disorders. Pediatrics. 2012;129(6): 86. Chen YP, Pope S, Tyler D, Warren GL. 1186–1189 66. Thornton A, Licari M, Reid S, Armstrong Effectiveness of constraint-induced J, Fallows R, Elliott C. Cognitive 75. Bailes AF, Greve K, Burch CK, Reder R, movement therapy on upper-extremity Orientation to (Daily) Occupational Lin L, Huth MM. The effect of suit wear function in children with cerebral palsy: Performance intervention leads to during an intensive therapy program in a systematic review and meta-analysis

Downloaded from www.aappublications.org/news by guest on September 27, 2021 PEDIATRICS Volume 143, number 4, April 2019 13 of randomized controlled trials. Clin 92. Sterba JA, Rogers BT, France AP, Vokes service utilization in children and youth Rehabil. 2014;28(10):939–953 DA. Horseback riding in children with with cerebral palsy. Child Care Health cerebral palsy: effect on gross motor Dev – 87. Facchin P, Rosa-Rizzotto M, Visonà Dalla . 2014;40(2):275 282 function. Dev Med Child Neurol. 2002; Pozza L, et al; GIPCI Study Group. 44(5):301–308 99. Bailes AF, Reder R, Burch C. Multisite trial comparing the efficacy of Development of guidelines for 93. Whalen CN, Case-Smith J. Therapeutic constraint-induced movement therapy determining frequency of therapy effects of horseback riding therapy on with that of bimanual intensive training services in a pediatric medical setting. gross motor function in children with in children with hemiplegic cerebral Pediatr Phys Ther. 2008;20(2):194–198 palsy: postintervention results. Am cerebral palsy: a systematic review. J Phys Med Rehabil. 2011;90(7):539–553 Phys Occup Ther Pediatr. 2012;32(3): 100. Palisano RJ, Murr S. Intensity of therapy 229–242 services: what are the considerations? 88. Huang HH, Fetters L, Hale J, McBride A. 94. Zadnikar M, Kastrin A. Effects of Phys Occup Ther Pediatr. 2009;29(2): Bound for success: a systematic review hippotherapy and therapeutic 107–112 of constraint-induced movement horseback riding on postural control or therapy in children with cerebral palsy balance in children with cerebral palsy: 101. Adams RC, Levy SE; Council on Children supports improved arm and hand use. a meta-analysis. Dev Med Child Neurol. With Disabilities. Shared decision- Phys Ther. 2009;89(11):1126–1141 2011;53(8):684–691 making and children with disabilities: pathways to consensus. Pediatrics. 89. Sakzewski L, Ziviani J, Abbott DF, 95. Lee J, Yun CK. Effects of hippotherapy 2017;139(6):e20170956 Macdonell RA, Jackson GD, Boyd RN. on the thickness of deep abdominal Equivalent retention of gains at 1 year muscles and activity of daily living in 102. Kwon JY, Chang HJ, Yi SH, Lee JY, Shin after training with constraint-induced children with intellectual disabilities. HY, Kim YH. Effect of hippotherapy on or bimanual therapy in children with J Phys Ther Sci. 2017;29(4):779– gross motor function in children with unilateral cerebral palsy. Neurorehabil 782 cerebral palsy: a randomized controlled Neural Repair. 2011;25(7):664–671 96. Sakzewski L, Ziviani J, Boyd RN. Efficacy of trial. J Altern Complement Med. 2015; 90. Snider L, Korner-Bitensky N, Kammann upper limb therapies for unilateral 21(1):15–21 C, Warner S, Saleh M. Horseback riding cerebral palsy: a meta-analysis. 103. Rosenbaum S, Wise PH. Crossing the as therapy for children with cerebral Pediatrics. 2014;133(1). Available at: www. palsy: is there evidence of its pediatrics.org/cgi/content/full/133/1/e175 Medicaid-private insurance divide: the case of EPSDT. Health Aff (Millwood). effectiveness? Phys Occup Ther Pediatr. 97. Tepas JJ III, Leaphart CL, Pieper P, et al. 2007;26(2):382–393 2007;27(2):5–23 The effect of delay in rehabilitation on 91. Sterba JA. Does horseback riding outcome of severe traumatic brain 104. Goldstein MM, Rosenbaum S. From therapy or therapist-directed injury. J Pediatr Surg. 2009;44(2): EPSDT to EHBs: the future of pediatric – hippotherapy rehabilitate children with 368 372 coverage design under government cerebral palsy? Dev Med Child Neurol. 98. Majnemer A, Shikako-Thomas K, Lach L, financed health insurance. Pediatrics. 2007;49(1):68–73 et al; QUALA Group. Rehabilitation 2013;131(suppl 2):S142–S148

Downloaded from www.aappublications.org/news by guest on September 27, 2021 14 FROM THE AMERICAN ACADEMY OF PEDIATRICS Prescribing Physical, Occupational, and Speech Therapy Services for Children With Disabilities Amy Houtrow, Nancy Murphy and COUNCIL ON CHILDREN WITH DISABILITIES Pediatrics 2019;143; DOI: 10.1542/peds.2019-0285 originally published online March 25, 2019;

Updated Information & including high resolution figures, can be found at: Services http://pediatrics.aappublications.org/content/143/4/e20190285 References This article cites 99 articles, 34 of which you can access for free at: http://pediatrics.aappublications.org/content/143/4/e20190285#BIBL Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): Current Policy http://www.aappublications.org/cgi/collection/current_policy Council on Children with Disabilities http://www.aappublications.org/cgi/collection/council_on_children_ with_disabilities Children With Special Health Care Needs http://www.aappublications.org/cgi/collection/disabilities_sub Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.aappublications.org/site/misc/Permissions.xhtml Reprints Information about ordering reprints can be found online: http://www.aappublications.org/site/misc/reprints.xhtml

Downloaded from www.aappublications.org/news by guest on September 27, 2021 Prescribing Physical, Occupational, and Speech Therapy Services for Children With Disabilities Amy Houtrow, Nancy Murphy and COUNCIL ON CHILDREN WITH DISABILITIES Pediatrics 2019;143; DOI: 10.1542/peds.2019-0285 originally published online March 25, 2019;

The online version of this article, along with updated information and services, is located on the World Wide Web at: http://pediatrics.aappublications.org/content/143/4/e20190285

Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. Pediatrics is owned, published, and trademarked by the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2019 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

Downloaded from www.aappublications.org/news by guest on September 27, 2021