LOUISVILLE As children grow and develop, we marvel in the developmental trail they blaze, often taking for granted the complex web of systems and experiences that play a role in each step along the path. There is no one absolute trail that all children must take from birth to adulthood, as there are some small side pathways that will lead to the same endpoint. However, over the last 30 years as a pediatric physical therapist, I have learned to be exceptionally picky in noting what these different paths can be and helping to determine what is an acceptable deviation from the trail and what is a problematic detour. Pediatric physical therapists can be instrumental in teasing out the underlying causes of developmental delay, assisting with diagnosis if there is one, and helping the family to move forward along their path.
If a child has a medical diagnosis, it is often well known what the alternative paths could be, so that families can be educated on what to expect and given resources that can be useful. For those with no diagnosis, alternative paths can be more difficult to identify and are often brushed off as temporary stumbles along the way, accompanied by the statement, “Give them time, they will catch up.” While some do catch up, others stray further from the path, making it more difficult to find their way back. Some basic red flags I look for in the first year of life include, but are not limited to:
2 months: poor eye contact, excessive low tone, excessive antigravity movement
4 months: poor feeding, difficulty with antigravity movement, not attempting to reach, not making any sounds
6 months: not attempting to sit, not making several sounds, not rolling, poor tummy skills
8 months: not shifting toys from hand to hand, not getting into sitting, not moving around the room in some fashion, not making 1–2 consonant sounds, not watching toys as they drop to the floor
10 months: not taking weight through their feet when supported in standing, not crawling, not banging toys together and dropping them into large containers, not taking baby food by spoon, not making a variety of consonant sounds
12 months: not pulling to stand, not turning toys over in their hands to explore them, not finger feeding, not using something consistently as a word to label a person or action.
There are also red flags for older children, and after the first year, many of them relate to the development of language skills. We usually like to see 50 words by age 18 months, 200 words and two words together by age two, and 300+ words with at least three-word sentences by age three. Not achieving these milestones would be a red flag, as would the two-year-old with no functional language.
Pediatric physical therapists can be instrumental in teasing out the underlying causes of developmental delay, assisting with diagnosis if there is one, and helping the family to move forward along their path.— Beth Ennis PT, EdD
Seeing these red flags only indicates a delay in development and could have many underlying influences. Therapists would rather see a child and determine that nothing is problematic than delay the referral hoping the child will “grow out of it” and end up with increasing delays. Sometimes giving insight to families about why their child has taken the path they have is enough to help them direct the child moving forward. Much of what we assist families with is what I call “play with a purpose,” a way to make everyday life therapeutic for their child. Empowering families with things they can do to assist their child, and then providing skilled services as needed, has proven to be effective in assisting children with delays to more fully engage in their communities.
Also of concern, is the growing number of teenagers being diagnosed with chronic pain syndromes, usually attached to a hypermobility diagnosis like Ehlers Danlos hypermobility type, and/or sometimes a pediatric fibromyalgia diagnosis. These diagnoses, and the resulting impairments and treatments, can often result in isolation from peers and withdrawal from typical school and other activities due to difficulty with pain management. Current pain neuroscience discussions around management recommend that patients work towards retraining their brain to allow appropriate levels of activity. We have had some success using aquatic physical therapy as a way to start increasing activity and encouraging teenagers to focus on things other than the pain. Activity levels can gradually be increased over time, and conversational distraction can keep children focused on things other than pain. Cardiovascular activities can also be introduced in the pool and gradually transitioned to land, with the goal of reintroducing patients to everyday activities. This is a long process, similar to the work being done with adults with chronic pain, with the intent of decreasing the use of significant amounts of pain medications.
In short, the focus of pediatric physical therapy is to assist families in helping children to participate fully in their role in society. Sometimes we are on the path for a brief period of time, other times we are partners on a long hike. But whatever the path, we hope to make the journey just a bit easier.
Beth Ennis, PT, EdD, PCS, currently serves as Chair of the Doctor of Physical Therapy program at Bellarmine University, President of the Kentucky Physical Therapy Association, and maintains a part-time private practice serving children and families in the Kentuckiana area. She is a developmental evaluator for First Steps, as well as an assistive technology provider and an aquatic therapist. As a practicing therapist for almost 30 years, Beth’s focus is on making sure children with disabilities engage fully in their communities.