presented by Tracy Stackhouse
Clinical reasoning for pediatric occupational therapists should be informed by neuroscience, developmental theory, occupational science, and clinical practice, including tacit clinical knowledge – all rich sources of evidence and inspiration. However, combining all of these sources of information into a format useful for in-the-moment clinical use can be daunting. In this course, you will be introduced to a clinical reasoning framework for combining sensory, affective, and motor processing into a relationship-based model to allow therapists to create and implement effect treatment plans as well as monitor progress. The aim of the clinical reasoning process is to help the therapist identify the underlying issues and provide comprehensive treatment and supports while building targeted skills in order to shift the adaptive functioning of the client/child. The clinical reasoning format lends itself as a guide to treatment to address the most common clusters of difficulties/diagnostic conditions seen by pediatric occupational therapists. This course will provide theory and practical information for enhancing OT clinical work with children with a broad range of neurodevelopmental conditions including those categorized as having sensory integrative difficulties or "SPD" concerns. Learning sound clinical reasoning allows the therapist to commit to excellence in their evidence-based approach to treatment and establishes the OT as a strong member of a multidisciplinary team.
Tracy Stackhouse is a clinical pediatric occupational therapist who has specialized in working with children, adults, and families affected by fragile x syndrome (FXS) and Fragile X related conditions since the late 1980s. Through this work, first at Children's Hospital in Denver, continuing at the UC Davis MIND Institute, and now at the nonprofit center she co-founded (Developmental FX), she has been able to provide continuity of care with hundreds of families affected by FXS. This allows her to offer a perspective to the families she serves and the colleagues with whom she collaborates about how FXS looks neurodevelopmentally. Tracy is committed to conducting research to advance the understanding and treatment of neurodevelopmental disabilities and FXS specifically. She is the director of the Developmental & Fragile X Resource Centre in Denver, CO, which is included as a part of the Denver Fragile X Clinic of the Fragile X Clinics and Research Consortium (FXCRC). She has been involved in fragile X clinical care and research since 1989 and has been involved with the National Fragile X Foundation (NFXF) since 1989, including active contribution to clinical materials and general advice. Tracy is a member of the Clinical Research Consortium of the NFXF, as well as a member of the Scientific and Clinical Advisory Committee. In 2013, she served as a consultant to Novartis during their clinical trial for a targeted treatment in FXS. Recently, she has been involved in the efforts to identify feasible and reliable neuromotor outcome measures that can be used in clinical trials. This project resulted in development of the FX Motor Battery, which is proposed to be further piloted in this study. Tracy is committed to the success of the proposed project and has a history of collaborative work with this research team that will support this project’s success.
What is clinical reasoning in occupational therapy and how does the process set up excellence in clinical practice? These are the questions addressed here. The course begins with an overview of the key concepts of clinical reasoning and how occupational therapists use the dynamic interaction between themselves, the client, and valued occupations, activities, and contexts to promote a person’s participation and satisfaction in life (AOTA, 2008). The demand for a pediatric OT is that they bring multiple levels of knowledge in an occupational context while delivering relationship-based and client-centered interventions that are up to date in terms of the science – this is a tall order and requires guided clinical reasoning to implement.
Utilizing the Model of Spatial-Temporal Adaptation provides a general developmental framework for considering any developmental skill. This is a foundation for pediatric therapy, especially a practice that is grounded in neuroscience and in the dynamic of therapeutic use of self. These elements are brought together in a conceptual model presented here. The Pediatric Clinical Reasoning Flow takes basic neural networks and applies them to identifying patterns of strength and need, so that treatment can be tied to the individual needs of the client. The conceptual framework builds on work across pediatric occupational therapy and, in particular, weaves in ASI from Ayres and the DIR framework from Greenspan to create a flow for fostering progress in basic developmental capacities. This conjunction of frames of reference streamlines modern pediatric OT clinical reasoning in a systematic way to increase consistency across providers.
Summarizing strengths and needs across developmental domains in a quasi-quantifiable manner allows for clarity in the treatment planning process and accuracy in progress monitoring. This produces a general developmental summary. This summary is then taken and utilized to devise a treatment plan following the STEPSI format (Stackhouse, et al. 1997). Finally, from the STEPSI process, intervention including direct treatment, activity selection, and selection of specialized intervention programs or protocols can occur. The intervention is extended to include connection to occupational roles, skills, and capacities and for home or community programming and includes consultation or coaching that might allow for implementation. This flow allows the clinician to integrate treatment and select appropriate methodologies based on the client’s profile, which is the aim of clinical reasoning. The flow includes progress monitoring with a modification of the COPM process, so that goal attainment guides the entirety of the reasoning model.