Physical therapists have provided services to infants, toddlers, and preschoolers with disabilities for many decades, long before federal legislation PL 99–457, The Education of the Handicapped Act Amendments of 19861 was adopted. This federal law supported the right to early intervention services for all infants, toddlers, and preschoolers with disabilities and those at risk for substantial developmental delays. The law and its later amendments supported the provision of physical therapy services to qualified infants, toddlers, and preschoolers as determined by a team of professionals and as outlined in the child and family’s Individualized Family Service Plan (IFSP).
Unlike early childhood educators and special educators, who are trained to work only with children, physical therapists, just like occupational therapists, speech-language pathologists, nurses, and physicians, are trained to provide service to individuals throughout the life span, from infancy through old age.2 As a result, there is little time in the academic or clinical preparation of physical therapists to gain the in-depth knowledge and skills of the complex limitations in body structures and functions, and restrictions in activities and participation that can affect infants and young children and how these affect their family.2–6 Bruder and Dunst7 note that of all of the personnel preparation programs they studied, physical therapy programs had the lowest level of training in the recommended areas of early intervention practice. They also note that there is little change in the shortcomings in personnel preparation in early intervention since first reported by Bailey and colleagues in 1990.3 Physical therapists who wish to serve young children and their families need to acquire independently the knowledge and skills necessary to provide effective and efficient services.
Recognizing the specialized knowledge and skills required to serve young children and their families in early intervention, the Section on Pediatrics of the American Physical Therapy Association (APTA) in January 1990 adopted a policy statement and competencies for physical therapists in early intervention.8 The competencies were meant “to serve as a guideline for personnel standards, staff development, and quality assurance. Competent physical therapists will probably not have expertise in every area but should strive to achieve competency in each area.”8 (p. 78) The purpose of this project was to revisit the competencies and to update their content to reflect present practice, legislation, and terminology.
Role of the Physical Therapist in Early Intervention
A number of core values and beliefs are common to practice and education in early intervention. Physical therapists recognize that the “quality of the relationships that parents and professionals establish on behalf of the child can enhance or diminish the effect of whatever technical skills and knowledge practitioners bring to their work with children and families.”9 (p. 53) Therefore, all early intervention professionals require an understanding of the scope of relationships between the parent and child, professional and child, parent and professional, and among professionals.9,10 It is essential for early intervention professionals to be family-centered and culturally competent.11 They must recognize the importance of service provision in the natural environment and that the natural environment is not merely a different location to provide traditional intervention but involves a process that promotes participation in the community in the roles and activities that the family chooses for the child.12
In the past two decades, the philosophy of early intervention has changed and the implementation of the new philosophy is still evolving.13 Early intervention provides the young child and family with a foundation to promote the child’s development and active participation as a member of the community. Physical therapists provide their unique contribution to the early intervention team through their competence in promoting sensorimotor function and activities by enhancing motor and perceptual development, musculoskeletal status, neurobehavioral organization, cardiopulmonary status, and effective environmental adaptation. Therapists need to provide this intervention in a manner that fosters family function and respects the family‘s values and culture.
Professional Development for Practice in Early Intervention
Consumers have a right to expect service providers to be competent in their specialized area or discipline of early intervention. Therapists need to be accountable for state-of-the-art, evidenced-based practice to foster the most optimal outcomes for young children and families served. Therapists wanting to specialize in early intervention will need to develop an effective professional development plan.
We believe that the philosophy of physical therapist professional development in early intervention is fourfold.2 First, therapists must develop competencies in the broad body of knowledge and skills related to pediatric physical therapy. Second, they must have knowledge of the professional, federal, state, and local rules, regulations and guidelines for practice in early intervention. Third, therapists must acquire the global knowledge and skills of an early interventionist, that is, child and family development and family-centered care. Fourth, they must be mentored during on the job training and maintain a dedication to life-long learning to promote state of the art, evidence based practice. Personnel preparation in early intervention should be discipline specific as well as interdisciplinary to reflect collaboration and the global philosophy of early intervention. Physical therapists need to be educated regarding how their unique contributions can be integrated into the philosophy of early intervention and they need the opportunity to be trained with other professionals to foster team collaboration.6,8,10,14
This philosophy of professional development is consistent with the key elements for training of infant/family practitioners that have been recommended by Eggbeer et al.9 They stressed the need for a knowledge base built on a framework of concepts common to all disciplines, the need for opportunities to observe and interact with young children, and the need for individualized supervision and collegial support, both within and across disciplines. This support should begin during training and continue throughout one’s professional career. Rooney et al15 investigated programs to determine successful strategies in implementing interdisciplinary personnel preparation for early intervention. They found that model programs have shared the commitment to family-centered, interdisciplinary service delivery.
Competency-based education is a sound approach to the organization, content, and process of professional development in early intervention.16–18 This methodology of learning is characterized as individualized, flexible, self-directed, and measurable. Competency-based education recognizes the current knowledge and skills of the learner and promotes integration of new abilities with previous experience. Competencies define performance outcomes, specifically in this case the outcomes necessary to effectively practice in early intervention. The Section on Pediatrics of the APTA competencies for physical therapists in early intervention8 have served as a standard for therapists, educators, administrators, and consumers to monitor the quality of service delivery. Those competencies needed to be revised to reflect current practice standards, changes in legislation, and terminology.
In 1998, the faculty of the Pediatric Physical Therapy Program at MCP Hahnemann University, Philadelphia, Pennsylvania, received a federal grant from US Department of Education, Office of Special Education to develop a competency-based Specialty Certificate Program in Early Intervention Therapy. The authors, who collaborated in the development of the original Section on Pediatrics of the APTA competencies,8 and the special issue of Pediatric Physical Therapy on Family Centered Intervention19 collaborated with others to update the competencies to serve as a foundation for the training program.
A four-step process was used to define the competencies that early interventionists should demonstrate when serving families and their young children with disabilities. First, the original Section on Pediatrics competencies were revised to reflect current regulations, terminology, and evidence-based practice. Second, multiple literature searches were conducted to identify other published standards of practice or competency lists for professionals across a variety of early-childhood related disciplines including occupational therapy, speech-language pathology, early childhood education, and early childhood special education. Documents that were reviewed included guidelines for practice of occupational therapy in early intervention,20 competencies for the practice of home-based services,21,22 and the jointly developed standards for professionals working in early education and intervention settings, adopted by the Council for Exceptional Children Division of Early Childhood (DEC), National Association for the Education of Young Children (NAEYC), and Association of Teacher Educators (ATE).23 A master list of competencies was developed from those reviewed.
Third, a series of six focus group surveys were held with parents of young children with disabilities to determine what families’ value in therapists and what roles, knowledge, and skills they expect from therapists. A total of 38 families, 37 mothers and 3 fathers, of 41 children with disabilities, participated in these focus groups. During the focus groups, a facilitator presented key questions that were structured to reveal competencies by asking parents to identify the characteristics they found most helpful about their child’s therapist, skills they would look for when selecting a therapist for their child and family, and what a therapist was able to do that they were not able to do. The focus group sessions were audio-taped and transcribed. Content analysis procedures were used to analyze the focus group responses. The complete methodology used with the focus groups has been described elsewhere.24
Fourth, these three data sources were then compared and combined to result in one final list of competencies that reflected legislation, professional literature and the perspectives of families. These competencies were reviewed regionally by 15 pediatric professionals on the steering committee, program faculty, and advisory board of the Specialty Certificate Training Program and subsequently were used by 16 therapists practicing in early intervention for further feedback and refinement. The competencies have been reviewed by the Practice Committee of the Section on Pediatrics of the APTA, comprised of experts in the field in the area of early intervention physical therapy.
The analysis of the published competencies in early childhood education and early intervention occupational and physical therapy revealed similarities in the knowledge and skills for any type of professional to practice successfully with families and their infants and toddlers. Existing competencies focus on the context of early intervention practices (ie child development, collaborating with families) to a much greater extent than they reflect specific skills that particular professionals should have that are different from the skills of other professionals in early intervention.
Nine themes, presented in Table 1, were identified from data analysis of the family focus group sessions.11 These themes represent the families’ appreciation of best practice, the family–therapist relationship, and logistical considerations. Families expect therapists to be knowledgeable in their discipline, to engage with the family and child, to provide coordinated and collaborative care, and to share information and resources.
The final competencies that were determined to be required by physical therapists practicing in early intervention are presented in Table 2. The competencies conform to the content areas specified for personnel preparation in early intervention10,25,26 as well as the specific knowledge and skills physical therapists must demonstrate.27–30 These competencies go beyond those outlined for entry level physical therapists in the Normative Model for Physical Therapist Professional Education.30 The primary change in the content between the 1990 and 2005 competencies is the addition of the concept of providing services in natural environments. The federal mandate of providing services in natural environments influenced the revised competencies in five of the nine content areas: context of therapy, coordinated care, examination and evaluation, planning, intervention, and administration. Changes were also required to conform to the Guide to Physical Therapist Practice 31 and the International Classification of Functioning, Disability and Health language.32 A description of all nine content areas follows.
Context of Therapy in Early Intervention Settings
Therapists should have an intimate understanding of legislation related to early intervention as well as to the practice of physical therapy. This knowledge is of utmost importance because the regulations of crucial legislation, such as Individuals with Disabilities Education Act Amendments (IDEA),33 are essential to the day-to-day functions of therapists in early intervention. Therapists communicate information regarding legislation to families and serve as an advocate for young children and their families.
Of central importance to early intervention, therapists need to be knowledgeable and skillful in family-centered care.11 Although this philosophy is crucial throughout the life span, for infants and toddlers, family issues are fundamental to the development and care of the child. Early-intervention therapists support parent–child interactions and family functioning to promote optimal child development.34,35 Physical therapists need to develop strategies necessary to achieve the goals of family-centered care: supporting the family unit; enhancing family competence; enhancing the growth, development, and functional independence of the child through a partnership with the family; and addressing goals that are important to the family and child.36
Wellness and Prevention
In their interactions with health professionals, community agencies, and the general population, physical therapists educate professionals and consumers about the early intervention system. Screening for neuromuscular, cardiopulmonary, and general developmental dysfunction has been identified as one of the major roles for physical therapists serving infants and preschool children.37 Physical therapists also assume a role in prevention as emphasized in the Guide to Physical Therapist Practice. 31 Prevention efforts can range from education about developmental activities for families to prevention of childhood accidents such as burns or head injuries.
Coordinated care has been hallmarked by families and professionals as a central factor of quality services.38 To provide coordinated care, therapists must develop effective skills in team collaboration39–46 When serving families and children in natural environments, such as the home and child care settings, therapists frequently work in isolation from other early intervention providers. Agencies and payor sources frequently do not have mechanisms in place for team collaboration; therefore, it is important for therapists to acquire communication and solution-focused skills to promote a team partnership.40 Skills in consultation are also needed to provide coordinated care. Therapists use teaching strategies to guide families, child-care providers, and other early intervention professionals in promoting the child’s function in daily activities.41
Evaluation and Assessment
IDEA33 defines evaluation as the process to determine eligibility for service and assessment as the process used to determine a child’s and family’s strengths and needs for service planning. These definitions differ from professional definitions found in The Guide to Physical Therapist Practice, where examination involves a gathering of history data, systems review, and tests and measures; and evaluation is defined as the making of clinical judgments based on a synthesis of the examination findings (pp. 42–45).31 Physical therapists in early intervention must integrate their professional examination guidelines within the context of the evaluation and assessment process of early intervention. They require effective strategies in family interviewing and observation of the child during play and daily family activities and routines.11 Therapists provide evaluations and assessments as part of an interdisciplinary or transdisciplinary team.47–49 Physical therapists contribute their expertise in the administration, teaching and interpretation of developmental, functional and motor assessments and they implement assessments in a family-centered manner. As part of the team process they synthesize findings related to motor development and adaptive function within the context of all areas of development and the participation of the child in home and community life. Physical therapists analyze critically the child’s abilities to determine if impairments in the neurological, musculoskeletal, cardiopulmonary, or integumentary system are related to functional or developmental issues.
Physical therapists should promote collaboration among team members and effectively enhance the family’s ability to participate in the development of an IFSP.50 Therapists provide the family with information, thorough explanations, and options to enable them to make informed decisions regarding outcomes and services. Knowledge of expected family and child outcomes in early intervention51 and skills in interagency collaboration are needed to provide a comprehensive family service plan.40 Therapists integrate knowledge of daily routines, family priorities, and community resources with their intervention strategies to develop a meaningful plan to address child and family outcomes and prepare children for transition from early intervention services.34
Therapists implement an intervention program that is family-centered and evidence-based, reflects developmentally appropriate practice, and promotes physical and mental health, function, and well-being.11 They support families and children in the home and community to promote participation and full inclusion.10,52–54 Competent therapists are reflective and critically evaluate their approaches.55 They are knowledgeable in activity-based and play-based approaches that optimize learning opportunities within natural contexts,56,57 and are skilled in environmental adaptations.58 Physical therapists provide their unique contribution through interventions strategies related to the neurological, musculoskeletal, cardiopulmonary, and integumentary systems.31
Federal, state, community, payor, and professional regulations and guidelines require providers to document services. Documentation is needed to communicate with families and other providers and to systematically record progress towards achievement of the IFSP goals. Documentation serves as a mechanism to monitor and implement modifications to the IFSP. Through documentation therapists provide evidence of their accountability and effectiveness of their services. Therapists require skills in communication, writing, and an understanding of related laws to become competent in documentation. The APTA has provided Guidelines for Physical Therapy Documentation in the Guide to Physical Therapist Practice.31
Working in early intervention is complex. Therapists need to take an active role in the administration of therapy services to promote quality service delivery. The day-to-day administrative issues, if not effectively handled, can overwhelm therapists and can become so time-consuming that actual service delivery suffers. Policies and procedures for work load management, documentation, team communications, professional development, supervision, reimbursement, safety precautions, and continuous quality improvement plans can provide a solid foundation so that therapists can maintain focus on the child and family.
Therapists must be responsible for the clinical decisions they make in practice. Part of this responsibility involves knowledge and application of research findings in the area of both early intervention and physical therapy. Individuals with Disabilities Education Improvement Act (IDEIA 2004)47 is very specific in the requirement that early intervention services be “based on peer-reviewed research, to the extent practicable” (118 STAT. 2751, SEC 636(d).4 Therapists need to access resources and reference materials to stay abreast with current knowledge as well as to investigate topics related to their changing caseloads. Therapists should disseminate case reports and clinical research studies to add to the body of knowledge in our field and must be committed to life-long learning to remain competent practitioners.
Early intervention literature, legislation, existing professional competencies and guidelines, family perspectives, and review by clinicians provided valuable information for updating the competencies for physical therapists working in early intervention. This systematic process was used to ensure that the competencies are comprehensive and useful for professional practice.
Surprisingly, given the 15-year gap between the original competency document and the revised competencies presented, only one major content change was identified: provision of services in natural environments. This addition substantially influenced more than half of the competencies areas and reflects a major philosophical and practical change in practice patterns in early intervention. Continued use of the original competency document would be a disservice in inadequately preparing therapists to uphold current legislation and practice standards in early intervention
Current research indicates that physical therapy students have the least amount of training in early intervention practices compared with students in early-childhood special education, occupational therapy, speech-language pathology, and multidisciplinary personnel preparation programs.7 Physical therapist students receive very little training in IFSPs, teamwork, natural environments, and service coordination. This research on the status of entry-level personnel preparation for physical therapists supports the need for post professional development to adequately prepare therapists to work in early intervention. The competencies presented in this paper can serve an important function by providing therapists, administrators, and educators an overview of the knowledge and skills that therapists need to acquire to provide quality care for young children and their families.
Professional development is critical to attain and maintain competencies in early intervention. Therapists need to utilize a variety of opportunities and resources available to enhance professional knowledge, skills, and attitudes. To ensure professional development authors and reviewers of the competencies suggest that therapists should:
- Seek a mentor or shadow an experienced early intervention physical therapist;
- Listen to families;
- Embrace a team approach and learn from colleagues in other disciplines;
- Read journals and professional texts in pediatric physical therapy and related areas of early childhood education and early intervention on a routine basis;
- Attend study groups, conferences, workshops, and continuing education courses;
- Serve on committees, advisory boards, work groups and task forces;
- Present at inservice education sessions, conferences, workshops, and courses;
- Publish on current issues;
- Promote the establishment of APTA credentialed residency and fellowship programs in early intervention;
- Seek pediatric specialization credentials through the American Board of Physical Therapy Specialties;
- Enroll in post professional certification or degree programs.
The purpose of this project was to revisit the 1990 APTA Section on Pediatrics policy statement and competencies for physical therapists in early intervention and update their content to reflect present practice, legislation, and terminology. A thorough review of the literature in early intervention in general and a synthesis of published competencies for early intervention professionals were completed. Six focus group surveys of parents of children with disabilities were conducted to ascertain their perspectives of the knowledge and skills important for therapists. This information was integrated into a listing of competencies that should be expected of physical therapists working in early intervention and was used in a training program to evaluate their validity.
Physical therapists who work in early intervention require specific skills and knowledge to effectively serve infants, toddlers and their families. Nine content areas with specific competencies were identified in which physical therapists should have expertise if they work in early intervention. Recent research suggests that physical therapists receive the least amount of training in the majority of recommended early intervention practices when compared to training in other disciplines. The competencies can serve as a guide for professional education programs and are useful to guide professional development.
The authors would like to acknowledge the considerable assistance of Pip Campbell, PhD, OTR, and Suzanne Mibourne, OTR, in all aspects of this project.
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Keywords:© 2006 Lippincott Williams & Wilkins, Inc.
child/preschool; clinical competence/standards; early intervention (education); infant; physical therapy/methods