Chapter I
Family centered care
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Introduction:
Family centered care involves the following themes:
 1- respecting each child and his family
 2-respecting racial, ethnic and cultural diversity and its effect on his family
perception
 3-facilitationg the choice for the child and family even it is difficult times
 4- Supporting the choice of the child and family to their care
 5-Ensuring flexibility in examination and treatment
 6-coolaborating with the child and family in all level of health care
 7-helping the child to discover his own strength , confidence
Barrier to family centered care:
Role conflict between family and therapist can lead to role stress
Role stress: a subjective experience result from lack of role clarity
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Stress Limiting Strategies (LEARN)
Listen with understanding to family perception
Explain your perception of the situation
Acknowledge the similarities and differences
Recommend the intervention
Negotiate an argument on the intervention
Family responses to Illness and disabilities:
According to ferguson: There are 8 aspects of family responses
1- Balancing the illness with the family needs
2-Developing communication acceptance
3-attributing positive meaning to the situation
4-Maintaing clear family boundaries
5- 4-Maintaing family flexibility
6- Engaging in active coping efforts
7- maintaining social integration
8-Developing collaborative relationships with professionals
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Culture
 Culture affect on how people view the disability and how people treat
with disability
 Culture is not biologically inherited but learned pattern of behavior
 Culture is transmitted from generation to generation
 Culture is shared between people
 Culture provides the effective mechanism for interacting with the
enviroment
Diversity versus Sensitivity
Culture diversity refer to range of culture represented organization
Culture sensitivity refers to culture competent work more effectively
Culture and parental expectation
There are many differences between cultures in;
Definitions and interperceptions of disability
Coping styles
Parental interaction styles
Access information and services
Fitting in educational programs
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Providing family centered care intervention
A model of family centered care intervention consists of :
1- Culture desire
Parents are personally desire
want to be engaged to be culturally aware
To be flexible and learn from others
2- Culture awarness
Self examination , own cultural back ground, own assumptions
3-Culture Knowledge
Process of seeking and obtaining a sound educational foundation
Understanding the intercultural differences lead to learning indvidual
differences
4- Cultural Skill is the ability to collect cultural data regarding patient problem as well
as performing culturally based physical assessment
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Some cultural Strategies for low literacy skills:
Remaining non judgmental
Involving family, patient
Asking patient simple questions
Simple instructions
Repeating the information
Use audio video information
Supporting the individual to be independent
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Benefits of Providing family centered care
Family presence during the treatment will decrease the child anxiety
Involvoing mother will help the child to recover faster
Presence of parents before surgery will assist in pain management
Family to family support have benifial effect on mental status of mothers
Family centered care is cornerstone in pediatric emergency department
Family centered care is important as a home vists for prenatal care of
pregnancy women
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Benefits to health care professional:
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A stronger alliance in promoting each child health and development
Improve clinical decision making
Improved follow after collaborative plan
Greater understanding family strengths
Improved communications among staff members
More competitive in health care marketing
Enhancing family child health care professional satisfaction
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Chapter II
Motor Development In Normal Child
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Variability of human growth and development
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Motor development and motor behaviors vary because of the influence of several
intrinsic and extrinsic factors
Developmental Theories
Physical therapists need a deep understanding of physical aspect s of growth
and development
1- Maturational theories;
 Maturational theories refers to as hierarchical theorie
 Developed by Piaget, Gesell, Bayley and Mcgraw in the early 1900
 Bayley produced at 1930 Bayley scale of infant development to assess
mental and motor development
 Maturational theories emphasize on the normal developmental sequence is
common to all children
 CNS is the major driving force of development
2- Behavioral Theories:
Behavioral Theories emphasis on conditioning behavior by the use of stimulus
response approach
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Developed by Pavlvo aand bandura
Manipulating the stimulus in the environment to create the response which can be
positively or negatively reinforce a particular behavior
Therapist may move a very distractible child from Gym room to a quite room to
achieve more concentration in doing the task
Manipulation of parameters of physical modalities to gain specific treatment response
3- Dynamic System theories
• It based on the work of Bernstein modified by Thelen
• No one system is a pre eminent director of development
• Each child and infant develop certain motor milestones according to many intrinsic
and extrinsic factors ( genetics, poor maternal or fetal nutrition, race, ethnic,
motivation for learning, cognitive abilities)
• It considers the effect of other systems other than CNS On development of the child
4- Central Pattern Generators
There are specialized neural circuits produce specific movements without conscious
effort known as Central Pattern Generators
In absence of sensory input CPG still produce specific rhythmic movement
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Tone and movement
patterns
Preterm neonate less
than 32 weeks
Full term more than 36
Posture Scarf sign; arm
passively moved across
the chest in supine
Full flexion no resistance
to passive movement
Physiological flexion
Resistance to passive
movement
Popliteal angle passively
move knee to chest
135-180 degrees
60-90 degrees
Ankle dorsiflexion
60-90 degrees
Less than 30
Slip through: holding
from axilla
NO SET shoulders
Complete slip
SET shoulders no slip
Pull to sit
Complete Head lag
Head held
Rooting reflex
Absent
Present
Grasp , ASTN reflex
Absent
Present
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NORMAL MOTOR DEVELOPMENT
SENSORY AND MOTOR DEVELOPMENT
• Sensory and motor development are independent
• Sensation not only provide inputs from the
environment but also create awareness on our
bodies, and feedback on variety of movement that
occur
• Early child movement and posture that occur as
stereotyped reflexes provide a foundation for
voluntary movement
• Movements become more integrated and
selective as the child has the ability to perform the
isolated movements
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• The neonate (Birth till 4 weeks)
• The neonate movements are
determined by reflexes
• In most position his body is flexed
except for his neck but periodically he
totally extends when he stretches or
when he held upright with his feet on
supporting surface
• Neonatal reflexes can be succeefully
observed when the neonate is
comfortable and alert.
Rooting reflex and suckling reflexes:
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• Moro reflex:
it occurs when the baby head suddenly falls backwards, The
arm immediately abduct with extended elbows , wrist and
fingers . The reflex disappears at the age 6 months
Galant reflex
It can be elicted by pricking on the paravertebral area of the
back from the bottom rib to the iliac crest the trunk flex
sideway towards the stimulus disappear by 2 months
• Crossed extension reflex
• When the nfant in supine With stimulating sole of the foot
the contralateral limb will flex then extend with adduction
and internally rotation
• Flexor withdrawal reflex:
• Stimulate the sole of the foot ---------------the leg quickly
flexed
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• Extensor thrust
• The leg will extend if you put a pressure on
the sole of flexed leg
• Crossed extension, flexor withdrawal,
extensor trust remain for 1-2 months before
integration
• Plantar grasp:
• If you put a pressure on the ball of the foot
the toes will flex remains till age of 9 months
• Grasp reflex when a finger is inserted into
the plam of the hand of the child followed by
traction to the fingers ------------strong total
flexion of child arm and fingers
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GROSS MOTOR DEVELOPMENT
• A dynamic posture is essenital frame work for
gross motor activities
• Dynamic posture requires normal posture reflex
mechanisms with normal postural tone ----stability and flexiability to allow for postural
changes.
• Normal motor development
• Supine
• 1 Month
• Flexion pattern
No head control
• Tonic neck reflex
Fisted hand
• Rolling to side as a block
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• 3 Month:
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Head approach to midline
Loosely closed hand
Pronated forearm
stronger fifth finger
• 4 Month:
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Tonic neck reflex
Start exploration of the hand
Head in midline
Alternated flexion and extension of fingers
• 6 Month:
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Rolling from supine to prone
Lifting of the head
lifting of the leg high
• 7 Month:
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Symmetrical supine position
Lift head as towards sitting
• 10 Month
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Less tolerated supine
sitting up
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Prone
• 1 Month:
• Suspension from prone------------------Head drops
• Prone position on table head rolls to side flexion
abduction in arm
• Flexion in hips, legs
• 2 Month:
• Better alignment of the head
more lift head
• 3 Month:
• Lift head with holding on forearm with extend hips
and knees
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4 Month
If suspended good alignment of head and trunk
Holding head, leg in midline position
Tendency to falls to side
5 Month
Swiming on the floor holding head up with flexed arm
With extended legs
6 Month
Rolling from prone to supine
7 Month
Well lifting of head
Lifting arm
8 Month
Moving from prone to sitting and vice versa.
Getting on hands and knees
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• 9 Month
• Pivoting on the trunk
backward
• 12 month
• Easy Crawling
• 15 Month
• Bipedal walking
Moving
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SITTING
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1 Month
From supine to sitting head sags and falls back
Rounded back
2 Month
From supine to sitting head erect for short period
Jerky movement
3 Month
supine to sit head sets forward but bobs in sitting
• 4 Month
• Supine to sit head slightly sags
• In sitting head erects forward, Lumbar
curve start to appear no cervical curve
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6 Month
From supine to sitting lifting of the head
Sitting on the chair with erected trunk
7 Month
Sitting alone
Leaning forward
Active balance
10 Month
Sitting for long period
Getting to sitting from prone
11 Month ----------------piovting in sitting
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STANDING
AND
WALKING
3 month
Supporting from axilla, partial weight bearing lift feet
4 Month
Supporting from axilla, extend leg tendency to flex legs
7 Month
Supporting from axilla More weight bearing bouncing
9 month
Full weight bearing
Walking sideway, erect position holding rail( holding on )
10 Month----------------Lowering on knee during standing
11Month--------------Walking holding rails
12 Month--------------- Walking holding one rail
15 Month------------------walking alone, ascending up stairs
holding on rail
• 21Month
• Squatting, ascending up, descending down stairs
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Prerequisites for normal movement
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1- Nervous system well formed, intact normally functioned
2- Good environment(adequate appropriate nutrition)
3-Challenges and rewards
4-Ability to learn, act
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Growth: quantitive changes in behaviour like length, weight and head
circumference.
Development: qualitative changes in behaviour skill like head control,
trunk control, ability to sit, ability to stand.
Maturation: Righting referred to elaboration of nervous system structures
Growth Motor: ability of the child to assume and maintain certain position
such as sitting, standing
1- Head Control
Prerequisites
1- Intact vestibular system
2- Intact eye and optical pathway
3- Intact muscular of the neck(muscle , jiont, ligaments)
4- Intact proprioceptors of neck
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• Age and steps:
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1- From birth to one month In prone position Tilting head
sideway to clear nasal airways
2- From 1-2 month raise head in prone to 45 degree
3- From 2-3 month prone on elbow raise head 90 degree with
support on forearm
4- from 3- 4 month prone with raise head and support on arms,
hands
5- Around 3,4 month----------stiffness of trunk , head ready for
sitting
6- From 3 to 6 month --------- come to supine , with pull to sit ,he
can control his head
7- From 6 to 7 month--------- come to side lying
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• 2- Rolling:
• Prerequisites:
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1- head control even partial
2- proper neck righting reaction
3- Ability to support on forearm and hand
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Sequence: It start as reflex in first seven month till be voulantary
Steps: From supine to sidelying , from prone to side lying , from
prone to supine
Age:
1- From supine to sidelying From 1 to 4 month
2- Come to prone 4 to 5 month
3- come to supine 5 to 7 month
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• 3- Sitting:
• Prerequisites:
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a- Head control
b- Trunk rotation and pivoting
c- Ability to extend trunk against gravity
d- Ability to support weight on arms.
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Creeping:
Like Quadruped position
Head, trunk control, Trunk rotation
Ability to make reciprocal movement
Ability to support on hands and knee
Age from 6- 8 Month
• 5- Standing:
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Head, trunk control, Trunk rotation
Ability to make reciprocal movement
Postural reaction, Protective Reaction
Steps: 10-10.5--------------pull to stand from supine
11- 12 month -----------------Standing holding on
13---15 month ---------------Standing alone without support
• 6- Walking:
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Prerequisites
Prerequisites
Head, trunk control, Trunk rotation
Ability to make reciprocal movement
Postural reaction, Ability to bear weight on lower limb
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SPEECH
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4-6 Weeks
Sounds which reflect to emotional and physiological state
12 Weeks
Sounds used for communication with others
8 Months
Simple short sentences
9 months
One meaningful word like ma ma
1 Year
Beginning of understand, Imitate adult
Using expression give it to mama
2 Year -------------More clear explanation
3 Year-------------Putting Words together to form a sentence
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Age :
12 month------------- Walking with support
15-18 month------------Walking alone (guard walking: abduction in both upper,
lower limbs with flexion in elbows
2 years----------- walk up and down stairs
2.5 years---------- jump, stand on one foot
3 years---------- jump or run
4 years------------------ walk in one line
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• Development of weight
1- Average weight for full term baby------------ 3.5 Kg
2 First 6 month of life-------------- increase weight by 20 gm/day
3- Rest of first year----------------increase weight by 10 gm/day
4- During 2 years weight decrease to 2.5 Kg
5- In next 2 years ----------increase average weight by 2 Kg/year
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Development of Length
At birth ----------- Average length 50 cm
At first year--------Average length increase 25- 30 cm
At two years----------Average length increase 12 cm
In next few years------Average length increase 6-8 cm
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FINE MOTOR DEVELOPMENT
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Shoulder stability, good posture and normal arm movements are
all useful for fine motor development
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Vision is not only essential for manipulating skills but also grasps
and release and good sensorimotor control of fingers and hands are
essential.
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Fine motor development occurs in 3 sequences:
1-Early reflexes and basic voluntary movements
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2- Development progress from the proximal parts of the arm to
distal
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3- pronation of forearm before grasp, grasp before release
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Early Reflexes and reaction
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Grasp Reaction:
Neonate does not show true grasp reflex but Tonic reaction of the
fingers. Insertion of finger in hand then traction -------------------strongly flex in whole arm
• 4 Month:
• Grasp reaction ----------- gentle stimulus touch radial or ulnar aspect
of hand
• 6-7 Month
• When stimulus touch ulnar side of hand-------pronation
• When stimulus touch radial side of hand-----supination
• Integration of hand with vision---------10- 11 Month
• Avoidance reaction;
• Up to the age of 6 months avoidance reaction occur when infant
grasps object , fingertips touch object
may involuntary open---------------- Droping the object
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Age
Skill
1 Month
Hand clenches on contact, Drops object
immediately
2 Month
Grasp in pronation
2- 3 Month
Retains rattle briefly
3 Month
Holds rattle actively
4 Month
Reaches with two hands
5-6 Months Release object by dropping or throwing
6 Months
Grasp cube with palmar grasp
7 Months
Grasp object in half supination
9 Month
Release object in larger container
10-11
Month
Grasp integrated with vision
12Month
Fine pencil grasp, release in small container
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12-18
Months
Grasps pencil in fisted hand
18 Months
Builds tower of 3 cubes, pencil held in pronated hand
2.5 Years
Builds tower of 6- 8 cubes, train from lines
3 years
Imitate bridge from 3 cubes, cut with scissor
4.5-6 Years
Hold pencil in tripod
Reaching :
4 Month : infant tries to reach out with flexed arms
5 Month: further reaching out
6 Month: Start to develop eye hand coordination
Eye hand coordination:
5 Month visually initated reaching-------------indication to
direction of reaching
6 Month visually directed reaching he can correct direction of
reaching
12 Month visually locate the object able to rech woith supination
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Voluntary Grasp:
3 Month : Infant will grasp a small cube only when it touch him
4 Month: Infant will be able to locate and grasp the cube
Ulnar Palmar Grasp:
Grasp with all flexed fingers and adducted thumb+ pressing the
object against ulnar side of the palm
Radial Palmar Grasp:-------------------6-7 Month:
Radial digital grasp------------ 8 Month
Scissors grip----------------------8 Month
Inferior pincer grasp--------------9 Month
Fine pincer grip-----------------------12 month
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