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 CHAPTER

24 Hospital and Pediatric Rehabilitation Services

Brian J. Dudgeon • Laura Crooks • Elizabeth Chappelle

reluctant to hospitalize children, given the potential for psy-

KEY TERMS chological reactions accompanying separation from home and
family. However, the need for careful, ongoing medical moni-
Hospital-based services Acute care
toring, specialized equipment and areas for diagnosis and treat-
Children’s hospitals Intensive care
Evidence-based practice Specialty units ments led to the inevitability of hospitalization for many types
Prioritization of care Oncology of conditions that can affect children. In addition to acute onset
Documentation Rehabilitation services problems, chronic disease and disorders appear to be on the
Medical teams Outpatient services rise among children in the United States and other developed
countries.74 These problems may relate to children’s challenges
with weight management, greater inactivity, and other lifestyles
GUIDING QUESTIONS that do not promote fitness.
With the unique specialized care needs of children, begin-
1. What are characteristics of children’s hospitals and ning in the late 1800s, hospitals developed to care exclusively
the functions of occupational therapists in these for and manage children’s health challenges. The first children’s
settings? hospitals in America began in the 1850s in Philadelphia, and
2. Which types of children are commonly treated in others soon followed. Today there are more than 150 such
hospital-based rehabilitation units, other specialized institutions. These community and regional efforts often led to
inpatient units, and outpatient therapy services? programs that addressed not only health, but also special edu-
3. What are occupational therapy interventions in cation needs of children. Although modern hospitals serve
children’s hospitals, and what evidence exists to medical concerns almost exclusively, educational needs are still
support interventions for children with common paramount in children’s lives, and, not surprisingly, school-
diagnoses? based services are often a part of children’s experience with
4. Which intervention approaches and teaching hospitalization. In addition to addressing needs for education,
strategies are commonly used in pediatric children’s hospitals also strive to create special environments
rehabilitation? that cater to children and families.59 Environmental features
5. How do occupational therapists establish such as art, colors, and areas that are friendly, warm, and invit-
collaborative relationships with other providers in ing allow space for play and enable families to gather and com-
interdisciplinary and transdisciplinary teams? municate. Volunteers assist with child and family services and
6. How do occupational therapists promote family fundraising to support costs and offset expenses for children’s
participation in rehabilitation and address transition care. Also unique to these settings are child life specialists who
home as part of discharge planning? attend to children’s emotional and developmental needs. They
may help reduce the stresses of a hospital stay by assisting
Children receive care at a hospital for a wide variety of diag- families in coping with the hospital experience by providing
nostic and intervention reasons. Although respiratory and information about play, child development, and adjustment
gastrointestinal problems are the most common reasons for to illness.
hospital care,24,27 rehabilitation services, including occupational The demands of an evolving health care system, varied
therapy, are usually provided to children with neurologic and medical conditions of the children, family dynamics, and hos-
musculoskeletal disorders. See Box 24-1. For children who pital’s milieu all influence occupational therapy practices. This
need hospitalization, issues of safety for the child and concerns chapter describes occupational therapy services to pediatric
about the influence of hospitalization on the child’s life experi- patients in the children’s hospital setting. It illustrates varied
ences often arise.13 Historically, physicians and families were models of service delivery and explains the roles and function
of hospital-based occupational therapists.
In the past, children who required hospitalization frequently
I wish to thank the children and families involved with Seattle Children’s Hospital, Seattle,
Washington, for their willingness to share their experiences. I also want to acknowledge the
had long-term stays, which included programs addressing
advice and help of colleagues from Children’s Hospital of Alabama in Birmingham for the socialization, education, and vocation.9,21 Currently, hospital-
preparation of this chapter. based programs focus on acute-onset problems and provision

704
 CHAPTER 24
BOX 24-1 Habilitation Versus Rehabilitation
A primary concept in the practice of pediatric rehabilitation
is the differentiation of habilitation and rehabilitation. For
children, the term habilitation is generally used to denote
attention to the child’s acquisition of expected age-level skill
and function. The term rehabilitation is used to reflect the
process of an individual working to regain skills and functions
that had been established but subsequently lost. For most
practitioners in pediatrics, the term rehabilitation is used to
encompass both concepts. This is true because disability,
whether new or chronic, creates ongoing challenges to
current function and future demands that evolve as part of
growth and development. In this chapter, the term rehabilita-
tion is used to express both concepts.
of specialized services for children and adolescents with dis-
abilities that may occur infrequently but are highly complex.
Hospital-based programs continue to evolve, in part because
of newly identified health threats. Hospital programs now
extend into the community, offering increased resources to the
community and emphasizing the partnership with families in
caring for a child with medical needs.
Characteristics of Children’s Hospitals
Hospital-based services may include inpatient and/or outpa-
tient care for the ill and injured, as well as prevention or well-
ness programs designed to reduce the need for future care
needs. Hospitals in which pediatric patients are served generally
fall into three categories: general hospitals, trauma centers, and
children’s hospitals. General hospitals strive to serve the needs
of the community in which they are located. Given specific local
populations, a wide variety of patients can be served in this type
of hospital, which often includes those of all ages, from an
infant to a geriatric population. The occupational therapist
working in the general hospital setting may serve pediatric and
adult patients. Hospitals that offer labor and delivery services
often have neonatal intensive care services that include occupa-
tional therapy services. Some general hospitals may also have
special units dedicated to serving the needs of pediatric popula-
tions; however, children with more involved or complex needs
are often referred to a children’s hospital.
Trauma centers are hospitals organized and certified to treat
patients with more acute life-threatening injuries. Usually situ-
ated in large metropolitan areas, patients taken to trauma
centers may have extensive musculoskeletal, neurologic, skin,
and internal organ injuries requiring multiple specialists. As in
the general hospital setting, the occupational therapist working
in the trauma center may serve patients who have a variety of
injuries or illnesses. Such centers often have burn units and
other special trauma units or programs organized to handle
the evaluations and treatments that initially focus on lifesaving
and sustaining procedures and to prevent unnecessary compli-
cations (e.g., splinting, positioning, evaluating oral motor
skills for feeding). As a child in such a setting becomes more
stable, additional types of interventions, such as training in
activities of daily living (ADLs) and age-appropriate play,
Hospital and Pediatric Rehabilitation Services 705
can be implemented. Stress on family members from having
their child in the trauma center may be compounded by having
other family members also receiving care, or the hospital may
be some distance from their home. Occupational therapists
need to be sensitive to the stress that families experience when
their children are in these centers. Once patients are stabilized,
and treatment has been established, they may receive ongoing
care in that particular hospital or they may be transferred to a
children’s hospital or general hospital closer to their own
community.
Children’s hospitals are specialty hospitals that offer a full
range of inpatient and outpatient services for infants, children,
and adolescents. The occupational therapist working with chil-
dren in such a hospital may be involved with children who have
a wide range of diagnoses and sometimes rarely seen condi-
tions, and thus may have limited information available on treat-
ment protocols or expected outcomes.
Region (Location) Served
Children’s hospitals, as specialized health care institutions, tend
to serve a broader geographic region than general hospitals.
This may result in a child being hospitalized a significant dis-
tance from home, increasing the sense of separation from
family, peers, and familiar environments. The distance between
the home and hospital may affect the family’s ability to visit the
child and remain in contact with the those caring for the child.
Frequently only one family member may be able to remain with
the child. This can pose additional challenges for the family,
creating not only a financial burden and psychological strains
of having a child in the hospital, but the distances between
family members may produce additional pressures. The size of
the service area and population of the region may also mean
greater cultural diversity and socioeconomic variation among
those served by the hospital. Diversity in clientele requires the
medical team to be sensitive to the cultural beliefs and practices
of the patient and family.72 The broader geographic region
served by most children’s hospitals usually requires hospital
personnel to interact with a great number of practitioners and
service programs across the region. This distance can pose
challenges for the hospital-based occupational therapist to
communicate with community-based occupational therapists
regarding the child’s intervention programs. Regardless of dis-
tance, hospital- and community-based occupational therapists
coordinate the child’s transition to home by accessing com-
munity resources and outpatient or school-based programs.
Missions of Children’s Hospitals
Goals of children’s hospitals often include effective advocacy
for child health, conducting leading-edge pediatric research to
improve on clinical outcomes, and creating and implementing
a model for family-centered and community-based care. These
and other program-specific missions influence the daily opera-
tions of these institutions and provide guidance about how
clinical care is approached and conducted. Promotion of child
health may be seen in local outreach programs in which chil-
dren’s hospital staff educate others in public schools and com-
munity programs regarding a wide range of children’s health
and safety issues. At the national level, advocacy for policies
and programs to promote public health, as well as health care
706 SECTION IV Areas of Pediatric Occupational Therapy Services
reforms that would enable pediatric health care coverage and
the conducting of research to prevent and address pediatric
health conditions, are often cited (see information provided by
the National Association for Children’s Hospitals and Related
Institutions [NACHRI]52).
Research on Systems and Care Outcomes
Research missions of children’s hospitals and research con-
ducted as part of clinical care can be broad or specific. They
are generally motivated by particular interests and needs identi-
fied by practitioners or other advocates. Research specializa-
tions may be stand-alone efforts of the hospital faculty and staff;
affiliated with local research universities; or part of regional,
national, or international research programs.
Two prominent types of research conducted at children’s
hospitals include assessing and reducing risks of care to reduce
iatrogenic causes of ill-health and developing best practices and
evidence for effective outcomes with specific clinical services.
NACHRI recognizes safety as a major concern and that hospi-
tals pose risks for infection and other medical and behavioral
consequences of care. For example, children’s hospitals’ staff
recognizes that infections are sometimes transmitted by hand
contact. Transmission of germs is thus carried from one patient
to another, sometimes by practitioners. Effective hand washing
habits have been difficult to implement, with most hospitals
striving to enable and monitor such habits by reminders, pro-
viding multiple cleaning opportunities, and enforcing routines
by monitoring and creating a culture of peer-to-peer feedback.
Other safety measures relate to body substance isolation
through conditional uses of gloves, masks, and gowns, with
proper disposal of at-risk materials. Departments of risk man-
agement and infectious diseases work to identify potential risks
and institute measures that prevent new and ongoing hazards,
usually through repeated trainings.
Occupational therapists participate in evaluation of clinical
services and client outcomes. For example, the status of ADLs
and instrumental activities of daily living (IADLs), discharge
placement, health-related quality of life, and well-being are
some of the typical measures used to document rehabilitation
outcomes.29 Occupational therapists use research to describe
medical and functional effects, validity of assessment tools
related to clinical decision making, and effectiveness of specific
treatment approaches or techniques. Over the past few decades,
increasing emphasis has been placed on outcomes and ways to
use research outcomes in evidence-based decision making.43
In pediatric rehabilitation, most outcomes research relates
to common diagnostic groups seen in such settings. For
example, Dumas and associates20 reported functional gains
demonstrated by children with a traumatic brain injury (TBI)
undergoing inpatient pediatric rehabilitation. The great-
est gains were made in mobility, but also in social function
and self-care for all ages of children. Bedell4 reported similar
findings from a series of children treated for TBI and other
acquired brain injuries, and also found that social functioning
continued to be greatly impaired. Among school-age children
at the time of injury, many with moderate and most with
severe injury show persisting and widespread cognitive, lan-
guage, academic, behavioral, and functional deficits. Although
many children with such injuries are identified, referrals to
therapy service may be limited6 and recommended interventions
may not be followed,56 making associated outcomes difficult to
predict.
Evidence regarding the efficacy of specific intervention strat-
egies is lacking because it is difficult and costly to conduct
research that analyzes the application of particular techniques
or rehabilitation strategies. Experimental research on rehabilita-
tion effectiveness is particularly difficult to conduct because of
the heterogeneity of the participants and ethical conflicts
encountered by suspending or withholding services to specific
children. Randomized clinical trials can be problematic,53 and
alternate research strategies have been proposed, such as those
with an emphasis on humanistic elements as part of therapeutic
practice34 and client’s views about process and outcomes.2 In a
review of services and outcomes in 12 hospital-based pediatric
rehabilitation programs, reporting on 814 admissions, the
intensity of specific service delivery was associated with client
outcomes.11 Those receiving more occupational therapy ser-
vices made the most gains in ADLs; those receiving more
physical therapy services made greater mobility gains; and those
receiving more speech-language services made greater com-
munication and cognitive gains.
Family and Child-Centered Care
Family-centered care of hospitalized children is a hallmark of
most children’s hospitals and has led to new insights and direc-
tions for care.22 To implement family-centered care, families are
designated as a member of the health care team and encouraged
to take an active part in decision making about treatments. The
occupational therapist working in a hospital setting in which
family-centered care has been adopted uses clear descriptions
to communicate evaluation results to the family, seeks input
from the family on which intervention outcomes for the child
have priority, and comes to a mutually agreed-on intervention
plan. As evaluations are completed and team meetings estab-
lished, the family has an integral part in decision making
about care.
The occupational therapist’s knowledge of age-appropriate
developmental tasks and understanding of the importance of
purposeful activity can help the child achieve a sense of control
in the foreign environment of the hospital. Occupational thera-
pists can also help other members of the medical team under-
stand developmental issues of concern and suggest strategies
to caregivers, family members, and others to support typical
development that may help the child better manage the hospi-
talization experience.
Accrediting and Regulatory Agencies
Pediatric rehabilitation advocates and service providers have
influenced and been shaped by accreditation processes. For
example, the Centers for Medicare and Medicaid Services
(CMS) designate requirements for services that are organized
and paid to provide “medical rehabilitation.” To meet CMS
guidelines for rehabilitation, rules are placed on such systems
that mandate specific program emphasis, dedicated space and
personnel, admission and discharge procedures, service inten-
sity, goal setting, and monitoring of progress toward goals.
Most rehabilitation programs also pursue voluntary accredita-
tion by groups such as The Joint Commission (TJC)39 and
the Commission on Accreditation of Rehabilitation Facilities
 CHAPTER 24
(CARF),12 as well as government agencies, such as the Occu-
pational Safety and Health Administration (OSHA), that set
standards regarding hospital operations. These organizations
assign additional mandates that also shape program character-
istics. Such guidelines may include integrated planning with
community-based services and continuous quality improve-
ment procedures. Every few years, accreditation standards and
procedures based on TJC and CARF shift their emphasis and
specification of essential requirements. Generally, after initial
accreditation, reaccreditation reports or visits are scheduled
every 3 years, and programs may be subject to periodic interim
reviews and reporting about their overall performance.
Employee education regarding safety practices (e.g., risk of
exposure to patient blood or other body fluids or to hazardous
materials) and attention to suspected abuse are also mandated.
Importantly, occupational therapists are required to report any
suspicion of abuse to designated personnel within the hospital
setting who, when appropriate, contact community support
services, such as law enforcement personnel or Child Protective
Services (CPS). Specific training in each institution regarding
reporting protocols must be established and provided to the
occupational therapists.
Children’s hospitals are often affiliated with similar institu-
tions, offering opportunities for consolidation of information
and equipment, achievement of common goals, and program
development.70 Hospitals may be part of a medical system
directed by a single administration and linking facilities that
share certain resources and specialized personnel. A spectrum
of care options, from acute and subacute rehabilitation, satellite
outpatient clinics and programs, and home health care may be
provided.
Reimbursement for Services
Inpatient services are typically funded by a combination of
private insurance carriers, Medicaid or special programs within
a state, and under some circumstances by Medicare. Occupa-
tional therapy has typically been recognized as a service that is
reimbursed in hospitals and medical rehabilitation units, home
health care, and, to a lesser extent, outpatient services. Medi-
care guidelines are generally universal across different states.
However, each state’s Medicaid rules and regulations and local
insurance companies have differing provisions related to the
funding of occupational therapy services and supplies or assis-
tive devices that may be required. Local regulations must be
reviewed to ensure that appropriate levels of reimbursement are
available and that families are informed about service options
and expected costs.
The length of stay in children’s hospitals varies, from as
short as a few days to weeks or perhaps months. As in other
hospitals, third-party payers and other regulators strive to
control costs by seeking shortened lengths of stay and transfer-
ring patients more quickly to less costly skilled nursing facilities
or home care, outpatient, or school-based services. Changes
within and across treatment settings can be problematic, often
creating confusion in families about entitlements and expecta-
tions for services. Clearly stated goals and time frames for
outcomes in each care setting are desirable.70 Case managers
who are familiar with funding rules and regulations work with
families and service teams to coordinate care and prepare the
family for transitions among care settings.
Hospital and Pediatric Rehabilitation Services 707
An issue of concern facing hospitals that provide services to
children is the cost of health care. In recent years, health main-
tenance organizations (HMOs) and preferred provider organi-
zations (PPOs) have proliferated, and many families are now
insured in these and other managed care plans. Prospective
payment systems, created within Medicare to estimate and
contain costs better, can have strong impacts on reimbursement
for services. This system uses preestablished rates of reimburse-
ment for diagnostic groups using the Healthcare Common
Procedure Coding System (HCPCS) for billing, which is based
on the American Medical Association’s Current Procedural
Terminology (CPT) codes. Payers take these guidelines into
consideration when authorizing care for inpatient stays. The
occupational therapist should be aware of payment limitations
when providing care and clearly communicate with families
when establishing treatment plans and explaining the scope of
services being offered.
Occupational Therapy Services in
a Children’s Hospital
Organization of occupational therapy and other rehabilitation
services in a hospital can vary. Programs in this chapter focus
on three broad types of services: acute care, rehabilitation, and
outpatient clinics. Each of these services is described in more
detail with case studies later in the chapter. In brief, acute care
services are those wherein therapy services are ordered directly
from a medical service or unit (e.g., intensive care neurology
and neurosurgery, oncology or cancer care, general surgery,
orthopedics, heart and pulmonary services, and, in many chil-
dren’s hospitals, transplantation services). Children are gener-
ally referred to acute care services for an occupational therapist’s
appraisal, interventions for immediate needs, and assistance in
planning transition to other service settings or discharge to
home. Pediatric rehabilitation services are often located in a
specific location of the hospital, which may include special
facilities with bedrooms and bathrooms to enable effective
independence training with lifts, mobility devices, and other
durable medical equipment. Spaces for individual and group
intervention, socialization, and group engagements are often
available as well. Outpatient services include regularly sched-
uled specialty clinics that address children’s and family’s
ongoing needs and individual children’s services in community-
based satellite clinics.
This chapter applies a systematic approach to hospital service
areas, including prioritization of care, evaluation strategies
used, goal-setting guidelines, and selection of interventions.
For each service area, the breadth of diagnoses and clinical
approaches is described.
Functions of Occupational Therapists
A primary focus of the occupational therapist in a children’s
hospital is on ADLs and other instrumental tasks associated
with independent living, education, and community participa-
tion. Occupational therapists use many frames of reference to
develop insights about the child’s function; establish interven-
tion priorities; and guide development of goals with the child,
family, and local care providers. In most forms of hospital care,
the occupational therapist follows a prioritization system that
708 SECTION IV Areas of Pediatric Occupational Therapy Services
focuses first on prevention of problems associated with illness,
trauma or disability; then resumption of the able self; and finally
restoration of lost skills and functions. Occupational therapists
use learning principles23,64,67 and clinical reasoning strategies.50
They often use behavioral and cognitive learning principles and
therapeutic use of self, blending technical competency with
personal caring.
Evaluation
In almost all cases, occupational therapy services in hospital-
based care are initiated through physician’s orders. Often
required by law or regulatory guidelines, occupational thera-
pists respond to an initial referral or orders and then negotiate
as necessary with the physician to add specific elements to
assessment and intervention activities.
A review of medical records and discussions with other
providers may form the initial basis for evaluation. Usually the
occupational therapist uses a clinical interview and observation
to initiate the assessment process, followed by physical exami-
nation and direct observation with the use of standardized tests.
Once the occupational therapist formulates hypotheses about
the impairment(s) and initiates intervention plans, the repeated
use of clinical examination and standardized tests serves as
objective measures of skill improvement. For diagnostic pur-
poses, the occupational therapist judges a child’s performance
against normed scores, but for evaluative purposes, the occu-
pational therapist usually judges a child’s scores on reassess-
ment against his or her previous performance. Selection of a
specific measure should be based on its reliability, sensitivity,
and appropriateness, given the child’s age and diagnosis.
The therapist may organize assessment of ADLs and IADLs
around checklists or other reporting tools that specify activities
and methods of rating the individual’s level of skill. The Func-
tional Independence Measure (FIM; UDS-PRO) and a pediat-
ric version, called the Wee-FIM II, were developed for children
of developmental age 6 months to 7 years.51,69 Eighteen specific
ADL tasks, including communication and social cognition, are
rated for dependence, based on the individual’s need for adap-
tation and assistance from a helper. The Pediatric Evaluation
of Disability Inventory—Computer Adapted Test (PEDI-
CAT)33 can be selected as a tool to report on ADLs, mobility,
social function, and responsibility shift for children 7 months
to 21 years of age. A wide number of tools may be used to
appraise performance skills.
Determining Intervention Goals
A critical component of all intervention planning is the occu-
pational therapist’s attention to goal development and setting
of outcome expectations. A collaborative process with families
is essential in specifying goals, although the goals must also
relate to the particular therapeutic techniques being used.8,49
Goals describe specific tasks that the child will perform,
conditions of performance, and type and frequency of assis-
tance needed. The occupational therapist may specify short-
term goals as interim steps toward reaching long-term goals.
He or she may define specific performance component targets
that link to meaningful functional outcomes (e.g., achieve eye-
hand coordination and manipulation skills sufficient for desktop
activities and writing at school).
Functional goals include specification of skills and the
expected level of independence. Levels of independence
describe varying degrees of dependence on personal assistance,
adaptive environments, and the use of assistive technology
(AT) devices. In the case of a child with greater and long-
standing disability, ADL goals may describe how he or she will
manage personal care assistance to achieve a self-managed
dependence. On most ADL scales, the level of independence
is rated as the amount of physical and cognitive assistance
needed as a proportion of the task (e.g., moderate assistance =
50%+ assistance of the amount of time required for a partial
task, whole task, and task transition assistance by a care pro-
vider). However, when concerned with the integration of
an individual back into his or her home, the concept of inter-
dependence among family members may be an important con-
sideration. Given the negative connotation associated with
dependence in Western culture, a more positive term to express
shared needs between family members may be termed interreli-
ance. Such language is suggested to focus on the shared duties
within households.
Interventions
For most children referred to occupational therapy, services are
provided in a relatively brief period, requiring the occupational
therapist to be highly efficient. Relatively brief intervention
periods necessitate that the occupational therapist establish
realistic priorities appropriate for the child’s projected length
of stay in the hospital. To do this, the evaluation process is
streamlined, goals prioritized, and discharge plans proposed at
the start of the admission and initial evaluation.
Preventing Secondary Disability and
Restoring Performance
Primary prevention is a term used to denote efforts that decrease
the likelihood of accidents, violence, or disease for everyone.
The terms secondary and tertiary prevention refer to specific
interventions, arrangement of care systems, and environmental
modifications to prevent the onset of problems in at-risk popu-
lations. Children admitted to the hospital are typically at risk
for developing a number of secondary disabilities. Prevention
measures may include safety in positioning and movement,
prevention of aspiration in swallowing, provision of orientation,
and appropriate measures to reduce stresses experienced in an
unfamiliar environment and prevent self-injury. Occupational
therapists must be aware of risks and avoid involving the child
in activities that would be harmful or perpetuate behaviors that
could hamper recovery. Complications from immobilization,
abnormal muscle tone, and other neuromuscular abnormalities
often necessitate careful attention to maintaining range of
motion, strength, and general fitness (Figure 24-1).
The occupational therapist typically addresses neuromuscu-
lar and musculoskeletal complications by using programs
designed to help the client maintain or regain normal range of
motion. Through the use of special handling techniques, occu-
pational and physical therapists carry out daily programs that
can involve slow stretch and joint mobilization. Occupational
therapists can correct existing limitations by using a combina-
tion of these techniques and specialized positioning and splint-
ing. The occupational therapist may also apply splints for
various purposes, including maintaining positions (e.g., resting
hand splint), increasing range of motion (e.g., dropout splints,
dynamic splints with spring tension forces, serial casting), or
promoting function (e.g., wrist cockup or tenodesis splints).
See Chapter 29.
 CHAPTER 24
FIGURE 24-1 Dynamic sitting balance is challenged with
an air-filled tube to address core trunk responses, seat and
foot pressure, with visual-head orientation practice that
simulate typical task demands in home or school activities.
The occupational therapist facilitates improved movement
and strength by using activities and exercises that are usually
incorporated into play routines. For children and adolescents
with musculoskeletal and lower motor neuron or motor unit
disorders, the use of progressive exercise and activity routines
may be appropriate. For those with brain injury that causes
upper motor neuron dysfunction, muscle tone and voluntary
motor control are focused on using various sensorimotor
techniques to promote postural stability, balance, visual
motor skills, and fine motor performance (Figure 24-2; see
Chapters 7 and 8).
Concern for wound healing and protection of insensate skin
are also essential to early planning and ongoing interventions
to achieve goals and education of the child and family. The
entire medical team, including the occupational therapist,
applies skin care, monitors the child’s skin, and implements
measures to prevention pressure ulcers. Pressure areas from bed
positioning, static sitting, and the use of orthotics call for
careful and routine skin monitoring. The child may require
several days to develop a tolerance to new positioning strategies
and orthotic applications. The child’s skin tolerance affects
decisions to change bed position, increase sitting time, and alter
the wearing schedule for orthotic devices.
Individuals often experience perceptual, cognitive, and
behavioral impairments after TBI, and similar concerns also
arise with other diagnostic conditions. With a prevention
emphasis, programs to ensure safety with physical activities and
handling of objects are critical. Environmental modifications
are often made to ensure the child’s safety. The occupational
therapist implements methods to help the child compensate for
Hospital and Pediatric Rehabilitation Services 709
FIGURE 24-2 Visual motor skills are addressed with
manipulative work using various materials and textures
to promote sensory recognition, tolerances, and skilled
performance.
disorientation and memory loss, although restricted environ-
ments and restraints may be necessary initially. Family pictures
or other familiar items from home may be used to create a
stimulating and more comforting environment. When the child
is more alert and aware of his or her surroundings, the occu-
pational therapist may use an educational approach coupled
with behavioral interventions. The occupational therapist
should inform the child of unit rules, post these rules, and
emphasize strict adherence to them. Occupational therapists
may use daily orientation programs and memory books to ease
the burden of confusion. It is important to teach the family
about the child’s perceptual and cognitive impairments and
create programs to help ensure the child’s orientation, safety,
and comfort.
Resuming and Restoring
Occupational Performance
The second level of priority for occupational therapy is a focus
on resuming the use of available skills and independence in
easily accomplished tasks. The occupational therapist empha-
sizes the able self by recommending that the child resume
doing tasks on his or her own and by suggesting how others
can support the child’s performance of ADLs. Enabling optimal
independence may be important for preventing the child or
adolescent from developing dependent behaviors or learned
helplessness. Efficiency demands placed on nurses often result
in the child becoming a passive recipient of care. The occupa-
tional therapist should strive to provide the child with sufficient
time to perform activities on his or her own. Early emphasis on
providing children with opportunities to make choices about
710 SECTION IV Areas of Pediatric Occupational Therapy Services
FIGURE 24-3 The occupational therapist provides the
child with cues and performance feedback while he carries
out an adapted IADL cooking task to address sequencing and
functional bimanual performance.
the types of assistance they receive or activities they pursue may
help them develop confidence in their skills and returning
abilities.
Once the occupational therapist negotiates goals for ADL
performance, he or she determines what the child needs to
learn, how such learning will take place, and how training can
best be organized within the clinical care setting. By embed-
ding therapeutic strategies in the child or youth’s natural
routine, he or she may discover simple strategies to resume
activity performance within a few sessions. Often the occupa-
tional therapist recommends structured routines and the use of
assistive devices and other modifications to achieve perfor-
mance and guide the child and other care providers in joint
problem solving to determine the most effective methods of
performance.
In guided learning of new performance methods, the occu-
pational therapist uses instructional aids, such as visual sup-
ports, visual modeling, touch cues, or verbal instruction. For
example, the occupational therapist may demonstrate the task
to be learned and have the child imitate. The occupational
therapist may also use verbal or manual guidance cues to assist
learning (Figure 24-3). For some tasks, predetermined scripts
or learning materials are available.54,55
Occupational therapy services also promote restoration of
lost skills and function using biomechanical, sensorimotor,
perceptual-cognitive, and rehabilitative approaches in various
combinations to restore function. The occupational therapist
helps the child or youth practice activities that selectively chal-
lenge an individual’s skills, with the expectation that these will
then transfer or generalize to occupational performance areas.
Biomechanical and sensorimotor approaches include the use of
therapeutic activities and exercise, splinting and positioning,
facilitation of movement, and use of biomedical devices such
as functional electric stimulation (Figure 24-4). Other physical
agent modalities such as superficial heat or cold may also be
used, whereas deep-heating techniques such as ultrasound are
often avoided because children’s bone epiphyseal (growth
plate) areas may be damaged.48 See Chapter 29 for additional
information on physical agent modalities.
FIGURE 24-4 The therapist provides guidance in strength-
ening both arms using an exercise device that monitors force
and repetition in a progressive manner.
Adaptations for Activities of Daily Living Skills
Rehabilitative approaches contrast with biomechanical and sen-
sorimotor techniques that are designed to address underlying
performance skills and factors. In the rehabilitative approach,
occupational therapists teach clients compensatory techniques
that use existing skills to restore occupational performance.
Occupational therapists teach clients to use adapted routines
and AT devices and modify environments to promote optimal
manipulation, mobility, cognition, and communication func-
tion. Basic principles apply to adapted performance of ADL
skills, described in Table 24-1. Principles of joint protection
and work simplification are commonly used; performance is
geared toward functioning in a barrier-free environment with
the use of familiar conveniences. Adaptations of a routine are
aimed at reducing complexity, ensuring safety, and minimizing
complications if errors occur.
Adaptive methods of ADL and IADL skills may include the
use of different strategies and devices (see Table 24-1). A cli-
ent’s reliance on AT devices may be temporary or permanent.
The early use of devices can increase safety or immediate func-
tion during recovery. The permanent use of devices is also
common when the child exhibits residual difficulties that neces-
sitate ongoing adaptations. When selecting devices, occupa-
tional therapists often choose to adapt existing equipment that
is already familiar to them or direct the family toward the pur-
chase of items with features that are more compatible with the
child’s special needs (e.g., enlarged handles on utensils, clothes
with color contrast, toys with specific visual, sound, or tactile
features).
Client outcomes may be optimized when occupational
therapists use complementary strategies to improve the child’s
skills, adapt functional activities, and modify environmental
contexts. For example, the occupational therapist may help the
child memorize a routine so that the child can guide his or her
own performance using verbal, visual, or tactile feedback. If the
child cannot memorize a routine, the occupational therapist
can prepare written instructions, pictorial step cues, and audio-
tapes with specific directions. Whole-task instruction and the
use of forward- or reverse-step sequence training are commonly
used methods. The occupational therapist can implement

TABLE 24-1 Rehabilitation Strategies*
Types of Limitation
Motor and Movement
Limited Range of Motion
Reach to all parts of the body and
objects within the immediate
environment
Limitations of hand motion
reducing holding and handling
of objects
Gross motor movements, such as in
bed mobility and elevation
changes
Decreased Strength and Endurance
Reduce the effects of gravity
Efficiency of movement and
reduced efforts are essential
Limit the need to sustain static
postures and prolonged holding.
Cardiac or pulmonary disorders
limiting ADLs based on
metabolic equivalents levels or
by direct monitoring.
Incoordination
Difficulty with manipulation skills
One-Handed Techniques
Replacing the stabilization function
of the other limb
Improving the skills of the hand
being used
Adapting tasks that require
alternating movements of two
hands
CHAPTER 24 Hospital and Pediatric Rehabilitation Services 711
Accommodations
Extended and specially angled handles (e.g., long-handled spoon or fork, bath brush,
dressing stick, or shoe horn)
Use devices that extend contact and prehension, such as reachers
Mount objects on the floor, wall, or table and bringing the body part to the device (e.g.,
boot tree for removing shoes, friction pad on floor for socks, hook on the wall to pull
pants up or down, sponges mounted in the shower to wash)
Replace reach requirement with use of a bidet for hygiene after toileting or manual or
electric feeders operated by switches to bring food to the mouth
Provide enlarged or differently styled handles that reduce the grasp requirement, such as a
T-handled cup. Replace holding functions by the use of universal cuff or C-shaped
handles. Friction surfaces may provide more secure grasp. When forearm rotation is
limited, swivel spoons or angled utensils may assist bringing food to the mouth.
Raise or lower surface levels to limit the extent of elevation change required. Lower the
bed height to allow ease in wheelchair transfers or raise it to ease in coming up to
standing from sitting. Raised chairs, toilet seats with toilet safety frames, and bath
benches reduce extreme changes in elevation required in transfers.
Use lighter weight objects, movements in the horizontal plane, reduced friction, and,
when possible, the use of body mechanics for leverage and gravity to assist movement
Electrically powered devices may meet goals of work simplification.
Extended handles may be necessary, but increased weight and forces required to handle
and apply leverage might increase difficulty.
Universal cuffs or C-cuffs limit needs for grasp and sustained holding. Use hooks and loops
on clothing and adapt fasteners by using Velcro, zippers, enlarged buttons, or elastic or
stretch shoelaces.
Have lever handles on faucets, doors, and appliances.
Use surfaces to support posture and proximal limb positions through bed positioning,
seating adaptations, and the use of arm rests and table surfaces.
Mount devices or stabilizing devices with friction from Dycem (nonslip material) or a spike
board, using enlarged lightweight objects
Change heights of surfaces and using devices such as sliding boards or hydraulic lifts to aid
movement
Schedule and pace tasks, simplifying work, using rest breaks during tasks in response to
cardiopulmonary limitations
Consider range of movement required, weight and resistance of objects being handled,
and positioning of the body in relation to objects used in tasks.
Achieve proximal stability when executing limb movements. Stabilizing the trunk and head
as one moves the arm and hand is thought to improve skilled movements.
Stabilize proximal segments of the limb while manipulating the hand by resting the elbow
and forearm on the table while using the wrist and fingers to manipulate objects.
Friction surfaces and containers that hold objects being manipulated may also be
suggested for stabilization with pads or a nonslip cup.
Increased weight may dampen exaggerated movements and tremor. Select heavier objects
or add weight to objects. Attach a weight to the arm or apply resistance to movement
by placing devices across joints, such as using elastic sleeves or a friction feeder.
Mount devices on stable surfaces and bring the body to these devices.
Many tasks can easily be carried out with practice using one hand.
If the hand being used was not previously the preferred or dominant hand, skilled
movements may take a greater amount of time to develop.
With perceptual and cognitive impairments, learning to use one hand may become
particularly difficult.
With hemiplegia, various dressing routines have been scripted that follow the rules of
dressing the affected limb first and avoiding the use of abnormal postures.
Assist or replace the stabilization function of the impaired or lost upper limb by mounting
devices or by use of friction surfaces.
Using specially designed devices or methods (e.g., a rocker knife or cutting-edged fork to
help cut; buttonhook to aid in buttoning; special lacing technique to aid in shoe tying;
a one-handed keyboard arrangement and training to aid in typing.
Continued
712 SECTION IV Areas of Pediatric Occupational Therapy Services

TABLE 24-1 Rehabilitation Strategies—cont’d

Types of Limitation
Perceptual and Cognitive Limitations (with or without movement disorders)
Performance errors caused by
faulty use of visual cues and
spatial orientation
Sequencing errors because of
memory or task attention
difficulties
Accommodations
Substitute for impaired skills by using more intact sensory, perceptual, or cognitive skills
(e.g., using a bell on the hemiplegic arm to draw attention if being neglected tactually
or visually)
Design step-by-step routines with cueing systems; repeat them in training
Use work simplification principles and modified equipment and adaptive devices as
substitution strategies.
Train children to rely on memorizing and reciting a verbal routine or follow audiotaped
instruction, written instructions, or pictorial cues.
With impaired visual perception, the child may need to learn reliance on tactile feedback
cues.
Use color-contrasted clothing, texture, or color-coding cues with objects. Appraise using a
mirror to give the child feedback about his or her performance.

Visual Impairment
Blindness or severe visual
impairment requiring a
substitute for vision by the use
of other sensory skills and
cognitive routines
Consistent organization of the environment and storage of items is necessary.
Use tactile identifiers such as raised letters on objects and locations of more transient items
described by a companion, or a standard technique, such as an analog clock location.
Build sound feedback into some items to aid in orientation or search.
Mobility specialists instruct use of techniques such as long canes or guide dogs for
ambulation or wheelchair guidance and the use of a leader’s arm for guidance in
walking.

*Occupational therapists use several strategies for specific types of dysfunctions to adapt activities for children with functional limitations.
In addition to these suggestions, ADL and IADL adaptations have been described (see Chapter 16) along with the uses of assistive technology
(AT) (see Chapter 19).

training over several sessions that capitalize on the times when
tasks are routinely performed (e.g., dressing in the morning
and at night or before and after swimming). As training pro-
gresses, the occupational therapist gradually reduces the extent
of external cueing from a person or instructional aids so that
only a minimal amount of such support is required for safe and
efficient performance. Often the team and family plan for the
gradual withdrawal of aides and assistance after the child is
discharged from the inpatient hospital setting. Occupational
therapists teach family members or staff strategies that promote
the child’s participation in daily activities, including school.
To help the child generalize learning from clinic to home,
he or she may visit the home. The home visits allow the child
and family to survey and collaborate in planning for equipment
needs, accommodations, and perhaps architectural modifica-
tions that would enable transition to home. Day or weekend
home passes for the child are desirable, when possible. Feed-
back from the family about the time at home can be important
to prioritizing goals, equipment, and family educational needs.
Documentation of Occupational
Therapy Services
Documentation of patient care is an essential component of
occupational therapy service provision in hospitals. Occupa-
tional therapy evaluation reports, intervention plans, patient
progress notes, and discharge summaries are used to commu-
nicate occupational therapy intervention to the physician, other
members of the medical team, patient and family, and reim-
bursement agencies. Format and frequency of documentation
are determined by the policies and procedures of the hospital
and occupational therapy department. Accreditation guidelines
regarding documentation are provided to institutions by agen-
cies such as TJC and CARF. Agencies that reimburse services,
such as Medicaid or private insurance, also have requirements
for documentation with which occupational therapists must
comply.
Occupational therapy evaluation reports, intervention plans,
progress notes, and discharge summaries are readily available
to other health professionals in a paper-based or online medical
record. Documentation of occupational therapy intervention is
also made available to referring physicians or other agencies in
the community, and copies become part of a permanent medical
record. Regardless of the format, documentation of services
must meet the criteria established by accrediting and reim-
bursement agencies.40
Scope of Occupational Therapy Services
Children are admitted to the hospital setting for many different
reasons, and they can move through different care units as
symptoms stabilize or effects become more apparent. Referrals
to occupational therapy may be made at admission, during a
stay, or near the end of a hospitalization. The occupational
therapist responds to the physician’s request and, when needed,
may ask for greater involvement in a child’s care or recommend
that other services become involved as well.
Children may be admitted for acute care of their illness or
injury. The occupational therapist performs an initial assess-
ment and provides caregivers and the child with instructions,
home programs, or follow-up outpatient services. The occupa-
tional therapist may also contribute to the diagnostic evaluation
 CHAPTER 24
of a child specifically admitted for a comprehensive evaluation
who is then transitioned to outpatient services. When a child
requires more extensive and comprehensive therapy interven-
tions as part of rehabilitation services, the occupational thera-
pist evaluates the level of functioning of the child, develops an
intervention plan, and involves the family in implementation of
the goals and objectives.
The patient with a single injury (e.g., a hand injury) or a
single episode of illness tends to have a short hospital stay, with
a predictable course of treatment. Some patients admitted for
an acute illness or injury may require extended rehabilitation,
depending on the severity of the injury and resulting complica-
tions (see Chapter 30). TBI and spinal cord injury are two
examples of injuries that require initial acute treatment and
long-term rehabilitation. The length of the hospital stay for
this type of patient during the acute phase of illness or
injury tends to vary because the potential for complications is
greater, and these patients need to be relatively stable medically
before being transferred to the rehabilitative service. See
Chapter 30.
Chronically ill children or adolescents may be hospitalized
periodically for acute episodes of an illness or complications of
an illness. Children with diabetes, cancer, or cardiac conditions
are in this category. When children who are hospitalized for
diagnostic testing or adjustment of medications experience a
comparatively short hospital stay, the occupational therapist
focuses on evaluation and intervention planning that is likely
to transfer to community providers. An occupational therapy
evaluation in acute care services focuses on the child’s func-
tional status within the context of the illness or injury that has
resulted in hospitalization.
Organization of Hospital-Based Services
Most patient care activity in hospitals is acute care. Acute care
refers to short-term medical care provided during the initial
phase of an illness or injury, when the symptoms are generally
the most severe. The degree of severity that categorizes an
illness or injury is matched to levels of acute care designed to
meet these needs. The occupational therapist providing services
to children during this phase must consider the long-term
implications of the illness or injury while addressing the acute
needs of the patient. Families may experience increased stress
during this phase and therefore may require that the informa-
tion be repeated or may need more time to process the results
from evaluations.
Critically ill patients who require continuous monitoring
and frequent medical attention, and patients who often need
special equipment to maintain or monitor vital functions, are
admitted to intensive care units (ICUs) or critical care units
(CCUs). Hospitals may have various levels of intensive care
units, each of which is designated for a specific patient popula-
tion or purpose. These can include neonatal intensive care units
(NICUs), pediatric intensive care units (PICUs) for older chil-
dren, and postsurgical intensive care units (SICUs). Personnel
who provide care for patients in ICUs receive special training
to enable them to respond quickly and effectively to meet the
needs of medically unstable patients in this challenging envi-
ronment (see examples in Chapter 21).
A child whose illness or injury results in hospitalization but
who does not need the continuous attention, high technology,
Hospital and Pediatric Rehabilitation Services 713
and specialized care of an ICU may be admitted to a medical
or surgical acute care unit. Medical and surgical units also tend
to be designated for specific types of patients. For example,
children requiring neurosurgical services may be cared for
on one unit, whereas children requiring orthopedic-related
treatment may be served on another. Children may also be
grouped according to age within the designation of these units.
Placing children of similar ages together can facilitate develop-
mentally appropriate care and allow for environments that are
well designed to match children’s and youth’s age-based
interests.
Children with infectious conditions may have a variety of
diagnoses that require isolation conditions. If this is the case,
these patients are often placed in special care units. Three con-
ditions that require a child to be treated in a special care unit
are (1) acute burns, (2) infectious diseases, and (3) bone
marrow transplantation.
Often chronically ill patients are admitted for an exacerba-
tion of their illnesses, for special treatments, or for complica-
tions. Diabetes, asthma, cystic fibrosis, and cancer are examples
of chronic illnesses occurring in children who may require
periodic hospitalizations. Patients who have progressive illness
may also be seen for acute issues relating to the next stage
of the disease process. For example, a youth diagnosed with
Duchenne muscular dystrophy may experience a decrease in
oral motor skills and subsequently be admitted for aspiration
pneumonia.
Hospital-Based Therapy Teams
In hospitals, the child and family benefit from a wide range of
medical care specialists and services that they can access as
needed. Hospital teams are usually led by physicians who are
trained as pediatricians and in other areas of practice, such as
neurology, orthopedics, or developmental medicine. An impor-
tant characteristic of medical teams is their dynamic nature.
Because the health care disciplines represented in a specific case
depend on the patient’s needs, the medical team is continually
changing. For example, a child with a feeding disorder who is
failing to grow and gain weight may have a physician, nurse,
occupational therapist, dietitian, and social worker as members
of the medical team. However, a child hospitalized with mul-
tiple injuries resulting from a motor vehicle accident may have
several physicians, nurses, occupational therapist, physical ther-
apist, speech pathologist, dietitian, respiratory therapist, and
social worker as members of his or her medical team. In addi-
tion, the team during one child’s hospitalization may change.
For example, the child admitted to the hospital for pneumonia
may initially be seen by the pulmonary physician and perhaps
a social worker, along with nurse(s); later the occupational
therapist and speech-language pathologist may be involved
when aspiration is suspected, and a physician from gastroenter-
ology may be involved later when it is discovered that reflux is
the culprit.
As a potential member of multiple medical teams within one
hospital, the occupational therapist communicates and collabo-
rates with professionals from many different health-related
fields. The occupational therapist may need to redefine or
explain the role of the occupational therapist continually to
other team members and develop an understanding of the ways
in which different team members’ roles complement each other
714 SECTION IV Areas of Pediatric Occupational Therapy Services

in the provision of services to children. Occupational therapists

employed by hospitals face increasingly complex challenges in
defining their roles in different care settings within one inte-
grated system and participating in a variety of medical teams
across the spectrum of care.

Team Interaction
Interdisciplinary care within a hospital or medical system is
common and mandated by most regulatory mechanisms. The
success of this collaboration often depends on a shared mission
that focuses the team’s energy and creativity. The team holds
family conferences on admission, at key decision points during
the hospitalization, and at discharge to ensure communication
and clarification of care recommendations with the family and
local care providers. In addition, the team conducts weekly
rounds to review the progress of each child and discuss any
changes in treatment plans designed for each problem.
The occupational therapist’s holistic concerns related to
health, function, and participation necessitate and are enriched
by the collaborative relationships among team members of
multiple disciplines. Partnerships between occupational thera-
pists and occupational therapy assistants can broaden the scope
and timeliness of services. The need for frequent re-evaluation
and trials with new strategies necessitate dynamic and shared
interventions. Team efforts are typical in medical systems.
For example, occupational and physical therapists often take
a joint interest in interventions to promote the child’s gross
and fine motor skills and make joint decisions about position-
ing, transfers, wheelchair seating, and functional mobility
(Figure 24-5). Occupational therapists collaborate with speech-
language pathologists to evaluate and plan interventions for
feeding and swallowing and augmentative communication.
Nurses and occupational therapists typically have collaborative
roles dealing with skills such as grooming, dressing, bathing, FIGURE 24-5 Functional mobility, often with walking aid
and training in special care routines of toileting and skin care. devices, enables greater freedom in activity selection and
Occupational therapists may work together with therapeutic accomplishment in a variety of settings.
recreation specialists and child life specialists to provide adap-
tive play and socialization through activity and community
outings.
A primary goal with children is to improve their participa- physical changes with bereavement,42,46,63 and this process can
tion and performance in educational programs. Children’s be further complicated by their own cognitive or behavioral
hospitals typically have teachers on staff, and, in conjunction impairments.17 An educational model may provide a helpful
with occupational therapists and other team members, these perspective. Recognizing that family members have a short
educators and developmental specialists address skills and amount of time to learn how to care for their family member
special needs that the child will have on returning to school. who is faced with new disabilities, rehabilitation team members
Psychologists and those who specialize in neuropsychology also devote their time and attention to understanding the family’s
provide suggestions for school placement and may work with priorities and learning preferences. In nearly all cases, the
occupational therapists to adapt learning strategies for the child typical routines of the family are severely altered by hospitaliza-
as he or she returns to the classroom. Social workers often tion and residual disability, resulting in worry, grief, and finan-
address issues of adjustment and coping with the child and cial hardships that necessitate a transformation of relationships.32
family. All team members strive to be sensitive and supportive Families function in different ways, and variations in styles
when educating family members to assume their new duties as influence effective coping.57 Healthy and resilient families show
care providers. Recommendations should seek a realistic balance strong and exceptional caring, open communication, balancing
within the family culture, established roles, and new responsi- of family needs, and positive problem-solving abilities.62 Fami-
bilities for care. lies with limited coping skills may need increased support and
help in identifying resources to meet immediate needs and in
Families coping with problems that they will face in managing the child
The occupational therapist must recognize that families are at home. In either case, the needs of families often change
often coping with tragic events or at least unexpected complica- during the rehabilitation process, requiring ongoing attention
tions that seriously affect their life processes. Children and to maintain a collaborative partnership that can achieve the best
adolescents are challenged to adapt to significant functional and outcomes for the child.
 CHAPTER 24
Acute Care Units
Intensive Care Unit Services
In the ICU, the child is often evaluated and treated at bedside
because of the critical nature of the illness or injury and the
need for constant monitoring of the child’s physiologic status.
Occupational therapy intervention in intensive care units sup-
ports medical priorities and goals for the child. It is essential
that the occupational therapist be knowledgeable about the
child’s diagnoses and potential precautions, implications of
medical procedures, use of life support or monitoring equip-
ment, and contraindications for certain activities or positions.
The occupational therapist monitors and knows immediate
responses to changes in the child’s vital signs, respiratory func-
tion, appearance, and symptoms.
Prolonged bed rest and immobility often occur as a result
of ICU stays, during which medical technology and equipment
and/or the need for restraints for the child’s safety and care are
in use. The average length of stay for a child in the ICU may
be just a few days; however, it may be extended if the illness
or injury is severe. The potential impact of extended immobil-
ity includes contractures, generalized weakness with decreased
endurance, and cardiopulmonary compromise. Occupational
therapists provide services to prevent these secondary problems
by using graded activities and soliciting the child’s participa-
tion to maintain strength and enhance functional capacities.
Although the occupational therapist may have goals of increas-
ing participation, independence, and endurance for the child,
the nurse or family may believe that rest is required. Discussing
the basis for the occupational therapist’s intentions includes
consideration of medical precautions to facilitate the team’s
desired outcome. Establishment of a routine, including regular
therapy times within the constraints of the ICU, can also help
with orientation for the patient and facilitation of regular par-
ticipation. Family members or other caregivers may also be
involved in carrying out interventions, such as range of motion,
throughout the day. This provides them with the opportunity
to become more involved in the care of their child during this
portion of their hospitalization.37,68
Occupational therapy interventions often include position-
ing recommendations and use of orthotics to preserve range of
motion and prevent deformity. A plan for wear or use should
be established and communicated with the family and other
care providers to ensure follow-through. Caregivers should also
be instructed on any potential side effects, such as pressure areas
with orthotics, so that interventions can be modified as needed.
Sensory deprivation and stress resulting from the ICU envi-
ronment may also complicate a child’s medical status and
recovery. The lack of privacy, immobility, and continuous
sounds and lights of the ICU provide the child with an atypical
sensory experience. In addition, the ICU setting has few indica-
tors of night and day cycles. Over a prolonged period, ICU
psychoses have been reported, in which the child may have
altered mental status.3,36 Occupational therapy intervention
may help counteract the effects of disorientation and sensory
deprivation by fostering the establishment of a routine for the
child and providing purposeful activities to facilitate cognitive,
psychosocial, and motor functions.1 Positive social interaction
and the use of entertainment and play activities may be espe-
cially helpful for reducing stress and promoting engagements
Hospital and Pediatric Rehabilitation Services 715
of young children in the ICU. Case Study 24-1 describes
intervention in the ICU.
General Acute Care Unit
General acute care units tend to be designated by medical
specialty. Children of various ages, with different types of con-
ditions and treatments, may be served in the same acute care
unit. Similarly, children requiring different types of surgery may
be admitted to the same general surgical unit for preoperative
and postoperative care. Designating units in this manner gener-
ally enables physicians and other members of the medical team
to use their patient care time and equipment more efficiently.
In acute care units, children tend to be more medically
stable and less dependent on life-sustaining equipment as part
of their care. A lesser need for medical monitoring may enable
them to benefit from greater involvement by rehabilitation
specialists, including the occupational therapist, who may
provide services at bedside or in the hospital’s therapy clinic.
Occupational therapists may be responsible for children in a
variety of acute care units, requiring them to be familiar with
the procedures of each unit, types of children admitted to the
different units, and nurses and other hospital personnel who
provide services. Case Study 24-2 describes interventions for
failure to thrive.
Specialty Units
Children’s hospital units are also often designated for specialty
care that congregates medical and support services for diagnos-
tic and treatment purposes. These may include a focus on
orthopedics, cardiac and pulmonary services, oncology, or
other hospital-specific organization of units, such as burns.
Oncology and Bone Marrow
Transplantation Units
A highly specialized acute care service is the oncology unit,
which may also include bone marrow transplantation services.
Children served on these units may include those diagnosed
with various types of cancer, immunodeficiency disorders,
hemophilia, and aplastic anemia. These units and services may
be housed close together and share some resources, including
staff, or may be located in separate areas within the hospital
setting.
The staff on the oncology unit provides care for children
who are newly diagnosed with cancer and undergoing induc-
tion chemotherapy, are receiving chemotherapy courses that
require close monitoring, may have complications from their
treatment such as fever with neutropenia, or may have under-
gone high-dose radiation and surgical tumor resections. The
occupational therapist working with these patients may encoun-
ter patients and families in different stages of the diagnostic and
treatment continuum. Because of the chronic nature of illness
for children and youth located on these units, the occupational
therapist may have time to develop relationships with the child
and family. Children may come in and out of the hospital
throughout their treatment, and the occupational therapist may
see the child for inpatient and outpatient therapy or coordinate
care across services. Children may also vary greatly in their
716 SECTION IV Areas of Pediatric Occupational Therapy Services
CASE STUDY 24-1 Intervention for Child in the Intensive Care Unit
Presenting Information
Michael is a 6-year-old boy admitted to the ICU with a diag-
nosis of necrotizing fasciitis with sepsis. He was initially seen
at the general hospital in his community, approximately 2
hours’ distance from the children’s hospital in the area. On
initial examination, Michael was found to have decreased
sensation, with decreased circulation to his fingers and toes.
He had a high fever (104.7° F) and was lethargic. He was
airlifted to the children’s hospital, and en route he began
experiencing organ failure, including a cardiac arrest. His
mother was able to accompany him in the airlift, but his father
had to drive because of space constraints.
Background Information
Prior to his hospitalization, Michael was a typically developing
young boy. He resided on a reservation with both of his
parents. He attended first grade at the local elementary
school, achieving average grades for his age. He also took
pride in participating in the Native American dance troupe
associated with his tribe and had been participating in exhibits
nationally with his troupe since age 3.
Michael was playing in the park near his home with friends
when he fell out of a tree and was deeply scratched by a
branch. Because there was a little bleeding, he did not return
home right away, but once he did return, his mother noted
that the area was red and slightly warm. She cleaned the area
with soap and water and placed Band-Aids on the cut. The
next day, Michael had a slight fever and was complaining of
generalized discomfort. By the second day, he vocalized more
physical complaints, would not let anyone touch his arm, and
his fever increased, even with medication and home remedies.
He was taken to his family physician. By this time Michael
had increased lethargy, was in and out of consciousness, and
had a high fever. He was subsequently airlifted to the local
pediatric hospital because of his quickly advancing disorder.
Medical and Occupational Therapy
Intervention
On arrival at the children’s hospital, Michael required a res-
pirator for ventilation support, and his medical status contin-
ued to deteriorate. Evaluation revealed staphylococcal sepsis
with intravascular coagulopathy, and he was admitted to the
ability to participate in treatments throughout the day or
during the week. Coordinating therapy with other medical
interventions may enhance therapeutic benefits by providing
interventions when the child’s energy is highest.
A bone marrow transplantation unit has certain similarities
to the oncology unit, with intensified therapies and additional
toxic agents used as life-saving treatments. Bone marrow trans-
plantations are used as part of a medical treatment protocol for
a number of life-threatening childhood illnesses, including
leukemia, aplastic anemia, immunodeficiency syndromes, and
tumors.73 Because of the complications of the treatment, the
occupational therapist must be aware of the stages that the
child is in during the transplantation process and must strictly
adhere to any precautions required.16,58,65
intensive care unit. During the first 48 hours, Michael con-
tinued to decline and showed evidence of organ failure. He
required continuous medical interventions, including dialysis,
ventilation support, and surgical intervention for increasingly
necrotizing digits, including amputation of several toes and
fingers.
With a focus on prevention, occupational therapy was
consulted early in his care to provide positioning and maintain
range of motion of affected and unaffected joints and soft
tissues. The occupational therapist fabricated orthotics for
both his hands and feet. He was required to wear them at all
times, except during dressing changes. His parents were also
instructed to carry out range of motion routines to maintain
his range and participate in his care.
Although Michael’s condition initially continued to dete-
riorate, necessitating amputation of one leg above the knee,
the other at the ankle, and all but two fingers, his family held
out hope that he would come through this devastating illness.
The parents called in the assistance of their tribal leaders to
provide guidance and use tribal medicine to enhance Western
medicine techniques. Leaders were granted permission to visit
Michael in the intensive care unit, with clear guidelines about
acceptable procedures that could be used.
During this time, the occupational therapist continued to
monitor positioning and range of motion. The occupational
therapist collaborated with nursing personnel to help position
Michael and his medical devices to enable his mother to rock
him in a chair at bedside. As his medical condition stabilized,
Michael was weaned from ventilator support and could
engage in strengthening and endurance activities. Occupa-
tional therapists also began to help Michael resume personal
ADLs by introducing adaptive devices to enable his indepen-
dence. Michael was provided with an appropriately sized
wheelchair, and gloves were adapted to ease the use of his
upper limbs so that he could propel the chair around the
hospital unit. As he continued to increase his strength and
function, he was eventually discharged from the intensive care
unit and transferred to pediatric rehabilitation services, where
his functional performance challenges were further addressed
by prosthetics fitting and learning adaptive methods and other
compensatory strategies to restore capabilities in personal care
as well as home and school functioning.
Oncology Treatment
During the initial phase of treatment for cancer, children
undergo a series of evaluations to determine cancer type and
staging, which includes determining whether the cancer has
metastasized. Patients generally receive a permanent line place-
ment through which they receive their chemotherapy. They are
often hospitalized for their induction chemotherapy, which is
the initial course and may be quite intense for some children.
Hospitalization is required initially to assess the effects of che-
motherapy and watch for any complications. Children fre-
quently decrease their oral intake during treatment, so nutrition
and hydration need to be carefully monitored.
As treatment progresses, children are often discharged from
the inpatient setting and are monitored between chemotherapy
 CHAPTER 24
CASE STUDY 24-2 Intervention for Child Who Fails to Thrive
Background Information
Failure to thrive (FTT) is a diagnosis given to children, fre-
quently infants and young children, who fail to grow or gain
weight. FTT may be designated as organic, arising from a
diagnosable physical cause, or nonorganic, which denotes
impaired growth without an apparent physical cause.28 Chil-
dren with FTT often require hospitalization and receive acute
care services that address complications, including immuno-
deficiencies, generalized weakness, and developmental delay
because of their malnutrition and behavioral difficulties.
Although organic FTT can be attributed to a specific
physical disorder, nonorganic FTT is primarily (but not
exclusively) associated with psychosocial factors. Disturbances
in parent-child interaction and development of attachment
early in life, difficult infant temperament and behavior,
maternal social isolation, and financial difficulties within
the family are some of the variables associated with nonor-
ganic FTT.51,59
The complexity of factors implicated in FTT emphasizes
the need for a coordinated team approach that offers medical,
nutritional, developmental, and psychosocial intervention.
As a member of the hospital-based team, the occupational
therapist may contribute to the diagnosis and intervention for
the child with FTT. A comprehensive occupational therapy
assessment provides the medical team with information
regarding the infant’s developmental status, feeding behav-
iors, infant-caregiver interactions during play and feeding,
and infant interactions with unfamiliar adults. Stewart and
Meyer66 also stressed that infant assessment emphasizes inter-
actional issues with the caregivers, whereas the assessment of
older children focuses more on behaviors in the feeding situ-
ation and attempts to differentiate between environmental
factors and neuromotor difficulties that may be affecting
feeding.
Occupational therapy intervention goals with a child who
has FTT may include ensuring effective oral-motor and
feeding skills and facilitating development. Promoting posi-
tive parent-child interaction may also be emphasized by using
strategies that help the parent understand the infant or child’s
behavioral cues and engage them with positive and develop-
mentally appropriate play experiences. This emphasis on
positive parent-child interaction also encourages parents to
develop behavioral expectations consistent with the child’s
level of functioning. Ongoing outpatient therapy is often
necessary following discharge to support goals established on
the inpatient stay and foster effective feeding behaviors.
Presenting Information
Kevin was a 3-month, 7-day-old boy brought to the emer-
gency room by his parents because of his unresponsive behav-
ior and concern regarding possible seizure activity. Initial
diagnoses included the following: rule out abuse, severe non-
organic FTT, and other risks, including seizures. Kevin was
noted to have bruising above both knees and over his right
buttocks. He had diaper rash and muscular wasting around
the left hip and extremities. He demonstrated poor oral
feeding and was subsequently admitted to the hospital for
observation and monitoring. An attending physician referred
Kevin to occupational therapy on the third day of hospitaliza-
tion to address oral feeding skills.
Hospital and Pediatric Rehabilitation Services 717
History
Kevin’s parents brought him to the hospital’s emergency
room after a home visit by a Child Protective Services worker.
On his hospital admission, his parents left and did not visit
during his week-long stay at the children’s hospital. His
maternal great aunt visited occasionally, and she expressed
interest in adopting him.
Kevin was born at term and weighed 5 pounds, 12 ounces.
He went home after a 48-hour hospital stay. He was hospital-
ized at 2 months of age for FTT, upper respiratory tract
infection, and otitis media. He was discharged to his parents
with home health nursing, a Child Protective Services referral,
and pediatrician follow-up. Kevin’s parents had missed all
follow-up appointments until they brought him to the emer-
gency room.
Medical and Occupational Therapy Intervention
A pH probe showed severe gastroesophageal reflux. An upper
gastrointestinal series was performed, which ruled out ana-
tomic abnormality. Stool samples were analyzed and showed
malabsorption, reducing substances, increased fatty acids, and
Giardia lamblia, all of which combined to reduce his level of
nutrient absorption and increase fluid loss. As a result, Kevin
was severely underweight and lethargic. Treatment for the
reflux included positioning on an elevated wedge and the use
of thickened feeds.
Kevin was evaluated by occupational therapists using clini-
cal observations of his oral-motor, feeding, and developmen-
tal skills. He demonstrated intact oral structures and sensation,
with functional oral skills for safe oral feeding. He had small
sucking pads with a weak suck and fair coordination of suck-
swallow-breathe. His suck and coordination improved with
support at his jaw and cheeks. Kevin’s developmental skills
were delayed, and he demonstrated poor state control, with
high irritability.
It was the occupational therapist’s impression that Kevin’s
weak suck, poor feeding, and irritability were from overall
weakness, malnutrition, and recent intubation, rather than
from a neurologic deficit. The occupational therapist devel-
oped a bedside plan of specific facilitation techniques to be used
during feeding. These included jaw and cheek support, external
tongue stimulation, flexion swaddling, decreasing external
stimulation, upright and well-aligned feeding positioning, lim-
iting oral feeding to 30 minutes, and turning off the continu-
ous pump that fed Kevin through a nasal gastric tube.
After implementation of occupational therapy recommen-
dations by nursing staff, Kevin’s oral intake increased dramati-
cally over the next 3 days, with the occupational therapist
feeding him once daily to monitor progress. Once the acute
feeding issues were resolved, the emphasis of occupational
therapy focused on developmental activities to improve self-
calming, visual tracking, and social interactions.
Kevin was referred for outpatient occupational therapy and
early intervention services before discharge. Child Protective
Services assumed custody of Kevin, and he was discharged to
a foster home with a weight increase of 2.4 pounds (follow-up
weekly weight checks were scheduled with his pediatrician).
The occupational therapist provided the foster parents with a
home program, including positioning, feeding, and activities
to promote Kevin’s play development.
718 SECTION IV Areas of Pediatric Occupational Therapy Services
sessions in outpatient visits. If the child does not have a nega-
tive reaction, or if the agents given do not have high levels of
toxicity, the child may receive chemotherapy on an outpatient
basis. Children receiving chemotherapy are often at high risk
for infections and are susceptible to contagious diseases; there-
fore, they need to take precautions, particularly if they are
neutropenic, which affects their ability to fight off disease.
Being neutropenic is a frequent cause for admissions between
chemotherapy sessions and can mean that children are readmit-
ted multiple times throughout their treatment.
The occupational therapist working with these children
should be aware of the cancer types and have general knowl-
edge of chemotherapy drugs and their complications, radiation
therapy effects, and surgical approaches that may be taken. All
personnel must adhere to infection control procedures. Occu-
pational therapists may focus on the prevention of secondary
complications by implementing strengthening, range of
motion, and endurance activities and resuming ADLs, feeding,
or play activities with patients, depending on their needs. Chil-
dren and families frequently develop a close relationship with
care providers because of the physical aspects of treatment,
along with the normalcy and expectation of survival that fami-
lies can perceive with daily activities. Cancer survival can be a
realistic outcome for many children, but residual difficulties,
including post-traumatic stress disorders, may be encountered
that necessitate attention years after medical treatment has been
discontinued.44
Occasionally cure is not an option for a child and family,
and the focus of treatment may change to be palliative in
nature. The occupational therapist working with the dying
child and his or her family must respect the cultural beliefs of
the family, along with the grief process. The occupational ther-
apist can assist with suggesting energy conservation techniques
to enable the child to continue to play and interact with family
members. Positioning may become particularly important as
the child develops increased weakness, difficulty with breath
support, or pain, and the occupational therapist can help fami-
lies problem solve alternative positioning to be close to their
child when comfort is of the utmost importance.18 It is also
important that the occupational therapist respect the family and
child’s wishes for withdrawal or discontinuation of services.
Some may wish to discontinue therapy intervention, choosing
to narrow the circle of support, whereas others develop a close-
ness with the occupational therapist throughout the treatment
and want to continue contact. The occupational therapist needs
to examine his or her own support systems, beliefs, and feelings
around end-of-life issues to assist the child and family during
this difficult time,71 during which communication with families
is essential,35 but receipt of palliative care approaches may be
limited.41
Transplantation Procedures, Complications,
and Interventions
The procedure for bone marrow transplantation involves che-
motherapy, radiation, or both before transplantation. This is
followed by the intravenous infusion of the bone marrow taken
from a compatible donor or from the patient before the pre-
transplantation regimen of chemotherapy and radiation. Chil-
dren who are undergoing treatment for disease processes that
do not invade the bone marrow may be eligible to undergo
stem cell transplantation.60 This involves the harvesting of stem
cells throughout their initial chemotherapy treatment while in
the remission stage. Although bone marrow and stem cell
transplantations both involve intense chemotherapy and radia-
tion, individuals who undergo stem cell transplantation experi-
ence lower rejection rates and fewer complications from
graft-versus-host disease (GVHD). The intense chemotherapy
or radiation before transplantation and underlying disease pro-
cesses cause severe immunosuppression in patients, making
them highly susceptible to life-threatening infections until the
new bone marrow is established and the child’s immuno-
hematopoietic system is once again functioning effectively.45,75
Continued long-term effects are also a complication of trans-
plantation. GVHD, abnormal neuroendocrine function, sec-
ondary malignancies, and avascular necrosis are some of the
complications seen in pediatric patients.59 Stretching, extremity
weight bearing, and general endurance exercises improve func-
tion in children experiencing these GVHD complications.7
Because these children have significant compromise of their
immune systems, the hospital environment is carefully designed
to reduce the risk of infection significantly. Common strategies
to protect bone marrow transplantation patients include room
isolation, reverse isolation, and laminar airflow in a clean or
sterile environment.76 Additionally, those having access to the
unit may be limited. Staff and visitors who have flu- or virus-
related symptoms may not be allowed onto units serving these
severely compromised patients.
Intervention by occupational therapists may include pre-
transplantation assessment of the child’s development and
functional abilities, as well as identification of limitations or
problems caused by the underlying disease process. After the
transplantation, the occupational therapist’s goals may be as
follows: (1) promote age-appropriate play, daily living, and
social participation; (2) enhance coping and interaction
skills; and (3) develop a plan for follow-up in the community.
Case Study 24-3 describes a child from initial diagnosis and
chemotherapy through the transplantation process and post-
transplantation intervention.
Rehabilitation Services
Levels of rehabilitation services can be subacute, acute, and
outpatient or ongoing care. Subacute rehabilitation services are
typically organized within skilled nursing facilities (SNFs) or
other long-term care settings. Such programs are designed for
children and adolescents who are too medically fragile or
dependent to be cared for at home but who are not yet able
to engage in or benefit from the intensive efforts of acute
rehabilitation.31 Such settings can also address later stages of
care, which may involve palliative care or extended stays. After
initial hospitalization, children and adolescents with moderate
to severe head injury, multitrauma, or other systemic illnesses
may be admitted to an SNF with subacute rehabilitation ser-
vices. In these settings, they may receive daily therapy to
prevent secondary complications and work toward goals of
greater independent function. This interdisciplinary care may
culminate in admission to an acute rehabilitation program or
planned discharge to an organized home- and community-
based service system of care.
Acute rehabilitation is characterized by inpatient hospital
units and services. The most common of these are dedicated
 CHAPTER 24
CASE STUDY 24-3 Intervention for Child with Cancer
Presenting Information
Danielle was a 21-month-old girl who was initially seen at a
general hospital near her home when she experienced a
decrease in standing and sitting balance. She was subsequently
admitted to a pediatric tertiary care center approximately 400
miles from her rural community. Initial examination and
imaging revealed a neuroblastoma in her spinal cord. Danielle
was immediately placed on the pediatric oncology unit, a
peripherally inserted central catheter (PICC) line was placed,
and chemotherapy induction was initiated. At initial presenta-
tion, both parents flew in with Danielle, although they had
separated just prior to diagnosis.
Background Information
Prior to diagnosis, Danielle was a typically developing
21-month-old girl, described by her parents as shy and
reserved. She resided with her mother; her father had moved
out 1 month prior to her diagnosis. Both parents were
English-language learners, having immigrated from South
America. They lived in a small town, with many community
friends available for support. Her parents moved from a large
city prior to conceiving Danielle to “obtain a simpler life-
style.” On hearing the diagnosis, the mother revealed that her
grandfather had died of a glioblastoma 1 year previously.
Medical and Occupational Therapy
Intervention: Oncology Phase of Treatment
Danielle was initially referred to occupational therapy imme-
diately after diagnosis. She had initial complications coping
with the increased noise and number of caregivers, along with
decreased performance. She was also seen by a child life spe-
cialist for developmentally appropriate coping strategies, such
as creating a calming environment and playing to facilitate
release of her emotions. Danielle did not sit independently,
and her overall strength was diminished.
Danielle was given chemotherapy to reduce the size of the
tumor and keep it from spreading. Because of its location,
tumor resection was not possible. Stem cell transplantation
was discussed at initiation of treatment as the best course of
possible cure for her cancer. Thus the medical plan was to
reduce her tumor size, obtain remission, harvest stem cells,
and prepare Danielle for transplantation. She was placed on
a chemotherapy protocol recommended for her tumor type,
and the family was informed of all complications, side effects,
and likely outcome possibilities.
In an initial assessment, the occupational therapist evalu-
ated Danielle’s performance skills and strength. She com-
pleted family interviews to learn about the child’s previous
skill levels, occupations, and particular interests. A plan was
made in conjunction with the parents and nurse for a daily
schedule, including times when Danielle could receive
therapy. She was moved to a corner room to decrease noise,
and times were posted when curtains were to be drawn to
allow the family private time. Pictures of caregivers, including
therapists, primary nurses, and physicians, were posted for
reference for Danielle and her parents.
Ongoing communication was established among all team
members through online documentation and team rounds,
and a care book was placed at Danielle’s bedside where
Hospital and Pediatric Rehabilitation Services 719
information and questions could be posted to facilitate com-
munication between parents and medical personnel further.
In addition, care conferences were held weekly, during which
all team members, including parents, discussed and planned
ongoing interventions.
Occupational therapy intervention consisted of age-
appropriate play activities to facilitate strengthening and con-
tinued motor skill development. Self-feeding was encouraged
and supported. The occupational therapist instructed family
members and the nurses on position strategies to increase
Danielle’s function and enable participation. Danielle did not
always participate in regular sessions because of medical treat-
ments that resulted in nausea and neutropenic compromise,
causing additional weakness and lethargy. During particularly
difficult periods, intervention sessions were limited to gentle
range of motion or were sometimes canceled for the day.
As medical intervention, including chemotherapy, pro-
gressed, Danielle experienced an increase in function. Her
occupational therapy intervention plan was continually revised
to reflect increased strength and independence. In response
to chemotherapy, Danielle began to have reduced oral food
intake. Strategies were implemented to help maintain oral-
motor skills and optimize self-feeding.
Danielle eventually transitioned to outpatient care, where
both her oncology treatment and occupational therapy con-
tinued. Because of behavior challenges, family requests, and
training expertise, direct physical therapy was discontinued.
Instead, a collaborative approach of consultation with the
occupational therapist at regular intervals to facilitate ambula-
tory and lower extremity skills was established. Her parents
divided care and alternated times when each parent would be
present.
Once the transplantation regimen was initiated, Danielle
was hospitalized for an extended stay. She underwent inten-
sive chemotherapy and radiation to ablate her current marrow
and subsequently received stem cell transplantation. During
the initial stages, Danielle experienced a significant decrease
in her strength and developmental skills. She had toxicity-
related complications, including sloughing of her skin and
mouth sores, which made participation in activities difficult.
As an added complication, Danielle also experienced life-
threatening pulmonary complications that required ventila-
tion support and necessitated a 2-week stay in the intensive
care unit.
Family stresses throughout this portion of her treatment
were enormous, and Danielle’s mother asked Danielle’s mater-
nal grandmother to come for support. Once there, interpret-
ers were called in to translate necessary information, as the
parents desired. Danielle eventually achieved slow engraft-
ment, and transplantation-related complications diminished.
As engraftment progressed, Danielle regained her play and
daily living skills, including ambulation. She was transferred
to outpatient services and continued to receive occupational
therapy intervention to address decreased strength and
delayed motor skills. She was discharged to her community
once she had completed her 90-day post-transplantation
evaluation and engraftment was clear. She continued to
receive ongoing occupational therapy in her community to
help facilitate progress in her development.
720 SECTION IV Areas of Pediatric Occupational Therapy Services
rehabilitation units within a children’s hospital. Another form
of organization is the specification of beds and services for
pediatric patients in a large rehabilitation hospital. Adolescents
15 years of age or older may be admitted to rehabilitation units
that commonly serve adults. Children and adolescents are
admitted to acute rehabilitation from other acute or transitional
care medical services within the hospital, other local hospitals,
or subacute rehabilitation settings. See Chapter 30. Overall,
admission to pediatric rehabilitation facilities and length of
inpatient stay is largely based on the child’s or youth’s level of
function and services needed.15
Essential to acute rehabilitation programs is the presence of
a broad range of services, including occupational therapy. The
mixture and intensity of services are planned to meet systemati-
cally developed goals. Such programs are characterized as
meeting three types of needs:
1. Organize and implement a planned approach for the
management of recovery and rehabilitation of children
post-trauma or with rapid-onset disorders.
2. Redirect care after onset of complications in children
with chronic disorders.
3. Provide an environment for specialized medical or surgi-
cal procedures that involves specific care regimens and
protocols.
Children and adolescents who sustain a sudden illness or
injury are the most common type of admission in acute reha-
bilitation. Table 24-2 indicates the common problems that
affect a typically developing child who experiences injury from
accidents, violence, or rapid-onset disease. Acquired injuries or
diseases represent a substantial health threat to children.77 Inju-
ries are the leading cause of death and disability among children
older than 1 year of age.25 TBIs, including closed head injury,
skull fracture, and penetrating brain injuries, are an ongoing
concern for children and adolescents caused by transportation-
related crashes, falls, recreational injury, and violence.47,61 Case
Study 24-4 describes rehabilitation for a child with a TBI.
Acute rehabilitation is also required for children who sustain
spinal cord injury (SCI) and multitrauma. Environmental
TABLE 24-2 Rapid-Onset Conditions
Type of
Onset Examples
Accidental Traumatic brain injury (e.g., closed head
injury injury)
Skull fracture or penetrating head injury
Burns and smoke inhalation
Multitrauma
Near-drowning
Spinal cord injury
Violence Multitrauma
Traumatic brain injury (e.g., gunshot wound)
Burns, iron burns, cigarette burns, and
scalding
Disease Central nervous system infection (e.g.,
processes encephalitis and meningitis)
Transverse myelitis
Guillain-Barré syndrome
Cancer
Organ transplantation
hazards, accidents, and abuse are also implicated in children
who experience burns, near-drowning, smoke inhalation,
carbon monoxide poisoning, or drug overdose.
Aside from known hazards, children also develop infections
that involve the central nervous system (CNS); they may sustain
a cerebrovascular accident or develop other neurologic disor-
ders, such as transverse myelitis or Guillain-Barré syndrome.
Cancer and its treatment may cause children and adolescents
to develop problems that necessitate acute rehabilitation. All
these disorders are characterized by typical development until
an acute health crisis causes a severe loss of function, a likeli-
hood of prolonged recovery with residual disability, and poten-
tial chronic health complications associated with disability. For
these children and their families, the purpose of rehabilitation
is to optimize recovery, prevent complications, and organize
and implement an approach to initial and long-term manage-
ment that optimizes function in family and community life.
Children with congenital or chronic disorders may also
require acute rehabilitation. Many with genetic disorders or
other congenital abnormalities or who experience chronic
disease often have delayed or atypical patterns of functional skill
development. These children are also at risk for complications
that can create a gradual or critical loss of function. Episodes
of respiratory complications, bony fractures and dislocations,
skin breakdown, or other systemic complications may be associ-
ated with functional deterioration. Children with cerebral palsy,
spina bifida, or other types of congenital deficits are included
in this at-risk group. Similarly, those with congenital limb
deficiency or arthrogryposis multiplex congenital syndrome
may have reconstructive surgery necessitating acute rehabilita-
tion. Children with osteogenesis imperfecta can have episodes
of curtailed functional gains after injury, and children with
juvenile rheumatoid arthritis and systemic disorders can experi-
ence periods of rapid functional decline. For these children, the
goals of rehabilitation are to prevent further losses and facilitate
the reacquisition of skills consistent with the pattern of func-
tional progression that was previously shown.
A third major group of children who receive acute rehabili-
tation services includes those who are hospitalized for treat-
ment with special medical, surgical, or technologic procedures.
For children with cerebral palsy, the use of medical interven-
tions such as selective dorsal rhizotomy, continuous intrathecal
baclofen, or other neurosurgical techniques to reduce spasticity
may involve admission to acute rehabilitation.26 Children
with severe pulmonary complications or those who become
ventilator-dependent may be admitted for acute rehabilitation;
their families learn how to perform care procedures and use
medical technology10; long-term outcomes can be positive.30
More and more children are also receiving organ transplants,
which may necessitate teaching special care procedures and
redeveloping fitness following a prolonged disease process.
These interventions often necessitate occupational therapists,
following specific evaluation and treatment protocols designed
to optimize functional outcomes.
Transition from Rehabilitation to
the Community
To facilitate continuity of care when the child is discharged
from a pediatric rehabilitation hospitalization, the team and
family develop a comprehensive plan of transition.74 For
 CHAPTER 24
CASE STUDY 24-4 Intervention for Child with Traumatic Brain Injury
Presenting Information
Devon was a 6-year-old boy with a severe traumatic brain
injury caused by an accidental gunshot wound to the head.
Immediately following this incident, he was evacuated to the
level 1 regional trauma center, where he underwent a decom-
pressive left craniectomy for evacuation of intraparenchymal
and subdural hematomas. Once stabilized and able to tolerate
multiple daily therapies, Devon was transferred 13 days later
to the regional children’s hospital for rehabilitative services.
At that time, he was delayed in following simple verbal com-
mands, not moving the right side of his body, unable to sit
unsupported and walk, and he did not speak.
Background Information
Previously healthy, Devon lived with his parents and 8-year-
old brother. His brother Daniel had just finished third grade
and Devon was to enter first grade in the fall. Prior to the
accident, both boys were at a friend’s house, where apparently
they found a gun. The gun was somehow fired, and Devon
was shot in the head. No one except for the children wit-
nessed the event. The family was understandably grieving and
his mom or dad had been at his side at all times during his
hospitalization. His mother described Devon as a warm,
loving child who knew everyone’s name in the neighborhood.
He loves playing with cars, riding bikes, and competing on
computer-based video games.
Medical and Occupational
Therapy Intervention
In addition to being cared for by the medical team and reha-
bilitation nurses, Devon received services from occupational
therapy, physical therapy, speech therapy, recreational therapy,
hospital-based school and rehabilitation psychology. Devon’s
family was supported by a social worker and the rehabilitation
unit care coordinator.
The occupational therapist completed an initial evaluation
with Devon and discussed a plan of care with Devon’s family.
Because Devon was not showing any movement of his right
arm, the occupational therapist started a daily range of motion
program to maintain full range of motion and fabricated a
wrist-hand orthotic to be worn when Devon was resting in
bed and at night. Once Devon tolerated this program well,
the occupational therapists trained his mother and father to
complete the range of motion program. As Devon began
vocalizing, however, he was difficult to understand; his parents
were concerned that he was unable to communicate basic
needs. The occupational therapist worked with the speech
therapist so that Devon would be able to point to a picture
symbol board with his left hand to communicate when he was
afraid, felt pain, needed to use the bathroom, and was hungry.
It was also important to Devon’s family that he remain
safe when he was not in therapy. The occupational therapist
Hospital and Pediatric Rehabilitation Services 721
taught Devon how to complete his daily activities safely, with
assistance and modifications as necessary, such as first dressing
with sitting supports on his bed and then progressing to
dressing while seated at the edge of his bed. Devon learned
how to use his nonaffected left arm as his newly preferred
hand to dress in loose-fitting, nonfastener clothing using one-
handed techniques and with equipment to modify the task,
such as elastic laces on his shoes and a ring on his zipper
pull. Devon learned how to manage a spoon and a fork, eat
with his left hand, and write his name. He practiced these
new skills in therapy and with his family, as well as when
attending the hospital schoolroom and with recreational
therapy. The occupational therapist scheduled Devon for
one-to-one therapy sessions twice each day and planned
morning personal ADL training and afternoon therapeutic
activities. In addition to structured ADL routines and orienta-
tion and memory programs, the occupational therapist also
engaged him in selected activities to facilitate the use of his
left arm and provide cognitive challenges in organizing steps,
following sequences, and sustaining engagement in familiar
and novel tasks. The occupational therapist taught Devon to
carry out daily range of motion and whole-body stretches to
maintain normal range and facilitate symmetric trunk and
limb use.
Devon continued to have difficulty performing activities
using his nondominant left hand, and left hand movements
were awkward and unsuccessful. The occupational therapist
cued and encouraged him to use both hands together, with
the left hand assisting the right hand. This strategy improved
his personal ADL performance so that the occupational
therapist discontinued the use of adaptive devices, such as
a button aid and rocker knife, after 2 weeks. Handwriting
with the right or left hand was not satisfactory for schoolwork
because of a language disorder, illegibility, and slow speed.
The occupational therapist introduced a computer keyboard
and initiated supplementary handwriting activities to facilitate
movement and augment function.
On discharge, his parents expressed concern about him
returning to school. They worried about how Devon would
adjust to school. Specifically, they wanted him to perform in
a regular classroom, eat lunch with his friends, and go to the
bathroom by himself. The occupational therapist provided
the school with results from standardized fine motor, visual
perceptual, and visual motor assessments and made recom-
mendations to the school so that they would understand what
assistance Devon would need. The occupational therapist
suggested accommodations for writing, cafeteria assistance,
and bathroom facilities. Devon returned home with his family
and continued his recovery, with outpatient therapies focus-
ing on sensorimotor skills and school-based therapies focus-
ing on enabling classroom participation and educational
performance.
722 SECTION IV Areas of Pediatric Occupational Therapy Services

example, a child with a brain injury often requires special educa-

tion services after discharge from the medical center, and readi-
TABLE 24-3 Outpatient Clinics and
ness to return to school may be particularly problematic because Programs Often Served by
of social-behavioral challenges.5 Team and family activities and Occupational Therapists
communication focus on the transition from rehabilitation to
school and community as soon as discharge is considered. Client Disorder Clinic or Services
Transition activities include interagency team meetings at
which school and rehabilitation team members are represented. Congenital disorders Spina bifida
Neuromuscular disorders Cerebral palsy
Ideally, at least one interagency meeting occurs in the rehabili-
Developmental disabilities Down syndrome
tation unit and at least one in the school. By sharing where the Fetal alcohol syndrome
meeting is hosted, team members get a realistic picture of the Rheumatologic disorders Juvenile rheumatoid arthritis
child’s environments. When the meeting is at the team’s home Systemic lupus erythematosus
site, most, if not all, team members who worked with the child Adolescent medicine Reflex neurovascular dystrophy
can be involved. disorders
In a visit to the school, the occupational therapist from the Craniofacial abnormality Cleft lip and palate
hospital shares information with the school-based therapists Orthopedic disorders Traumatic hand injury
related to concerns, priorities, and results of intervention Congenital limb deficiency
approaches (i.e., what worked and what did not). The child’s Rehabilitation Traumatic brain injury
Spinal cord injury
rehabilitation team helps problem solve issues regarding the
Constraint-induced movement
school’s accessibility and possible modifications to the class-
therapy program
room and curriculum. Visits to the child’s classroom can help Muscular dystrophy Duchenne muscular dystrophy
identify accommodations that need to be in place. During these Spinal muscle atrophy
visits, the rehabilitation team can present information to the Limb deficiency disorders Congenital amelia
other students in the class about the child’s disability, his or Traumatic amputation
her rehabilitation, and types of changes that they may expect Cystic fibrosis Cystic fibrosis
in their peer. When a child returns to his or her preinjury Assistive technology Seating and positioning
classroom, the hospital therapist can provide an in-service pre- Wheelchair control
sentation about the injury so that the student’s peers have Augmentative communication
Computers and information
expectations about his or her behavior and personality or, in
technology
the case of severe burns, about the student’s appearance. In
Environmental controls
addition, before discharge, the child should visit his or her
school and other important environments to determine what
accommodations will need to be made.
The rehabilitation team often monitors the child’s progress Outpatient clinic programs that often include occupational
during the first few months after discharge. The child may therapy services are listed in Table 24-3. Such programs may
continue with outpatient services while initiating school-based be scheduled weekly, monthly, quarterly, or even annually, as
services. Consistency during the transition is maintained by the needed. Sometimes these programs are conducted away from
family members, who ultimately support the child through the the hospital facility at community sites such as schools. Occu-
transition to the home. In support of this, the teams involved pational therapists who work in specialized hospital programs
provide the parents with comprehensive information about the are provided with unique exposure to otherwise uncommon
special education system in their community, their rights as diagnoses and clinical procedures and can pass this experience
parents of a child who newly qualifies for special education on to other families and therapists as a conduit of information
services, and other community programs, supports, and and new ideas. For example, school personnel may have limited
resources that they can access. experience with children who have arthrogryposis, brachial
plexus and limb deficiency, or various forms of muscular dys-
trophy, whereas the hospital clinic therapists would have regular
Outpatient Services experiences with these disabling conditions. Specific study and
preparation for consultation are suggested for entry-level thera-
Another major component of pediatric rehabilitation exists in pists and can be an important skill for the occupational therapist
specialized outpatient services and clinics that provide ongoing to develop as part of pediatric rehabilitation,19 particularly in
care. Typically, as part of children’s hospitals or rehabilitation working with more local, community-based therapists who may
hospitals, interdisciplinary outpatient clinics are organized to have limited experience with some diagnostic conditions and
provide monitoring and interventions for children who experi- related treatment approaches that are used.
ence particular types of chronic health risks and disabilities. Outpatient services are important components of the total
Occupational therapists often provide follow-up and follow- spectrum of hospital care and may be provided at the hospital,
along attention to children and families after hospitalization, at a hospital satellite center, or as part of an interdisciplinary
but many of these children are never hospitalized. Occupational hospital-based clinic (e.g., rheumatology clinic, neurodevelop-
therapists who work at these clinics often focus on the child’s mental palsy clinic, special feeding clinic). Outpatient occupa-
or adolescent’s health status and development, emphasizing tional therapy is generally provided for one of three purposes:
functional progress and participation in home, school, and (1) as part of a diagnostic assessment, (2) to provide needed
community activities. intervention and assistive technology after hospital discharge,
 CHAPTER 24
CASE STUDY 24-5 Occupational Therapy in Spina Bifida Specialty Clinic
Stacie is an 8-year-old girl with midlumbar myelodysplasia.
She ambulates with ankle-foot orthotics (AFOs) and uses
Lofstrand crutches for longer distances at this time. Although
she is functional for mobility in her home and at school, her
future mobility demands may necessitate use of a wheelchair.
She exhibits delayed coordination skills and less than expected
quality and speed in handwriting tasks. Stacie uses a computer
to complete some school work in her third-grade integrated
classroom.
Stacie is assisted at home in dressing (managing clothing
fasteners) but is otherwise independent with her morning and
evening ADLs. With a neurogenic bowel and bladder, she is
on a clean intermittent catheterization (CIC) program and
daily bowel program (BP). Her mother has traditionally done
her catheterization and is trying to transition to have her
perform more of it on her own. At school, a nurse assists with
her catheter routine twice daily. She is somewhat successful
with her bowel program, typically having bowel movements
in the morning or during the evenings at home. Timed pro-
grams include the use of diet and suppositories. Occasional
bowel accidents are acknowledged, and she uses pull-ups to
manage.
Although many of the activity and participation concerns
with Stacie are addressed as part of school therapy and
reflected in her individualized education program (IEP), the
role of the specialty clinic follow-up has two major purposes.
One of these is to monitor her motor skill development and
status carefully. Children with spina bifida often have neuro-
surgical shunt placement early in life to reduce hydrocephalus.
These shunts can become obstructed, and families, as well as
or (3) to provide occupational therapy intervention for indi-
viduals with disabilities or other medical conditions not requir-
ing hospitalization.
Outpatient services provided as part of an interdisciplinary
specialty medical clinic usually have a specific focus (e.g.,
feeding clinic, behavioral disorders clinic). See Case Study
24-5. Occupational therapy services in specialty clinics are
limited because children typically attend only once or twice a
year. In some cases, the occupational therapist functions as a
consultant, completing an assessment, and then making recom-
mendations to the physician. In other cases, the occupational
therapist is an integral part of the decision-making team and
may be involved in child assessment, intervention or equipment
recommendations, or the provision of orthotics and adaptive
equipment.
In AT clinics, occupational therapists evaluate how the child
could benefit from the use of aided and augmentative com-
munication systems, computer access and use of information
technologies, therapeutic seating, powered mobility, or other
technologies that enable environmental access and control.
These applications of special procedures and AT devices are
characterized by preplanned and often short trials leading to
the prescription of devices.38 Efforts culminate in intensive
family training and transitions to follow-up in the community,
often as a partnership with local providers in the environments
in which the devices are used.
Hospital and Pediatric Rehabilitation Services 723
service providers, are vigilant in attending to signs of shunt
failure. Worsening of coordination and visual-perception skills
can be one of these signs. The occupational therapist at the
specialty clinic often performs normative hand function
assessment to determine stability of performance over time.
In this clinic, the occupational therapist measures grip and
pinch strength and coordination testing using the Jebsen-
Taylor Hand Function Test, which has norms for children,
adolescents, and adults of both genders. Developmental
visual-perceptual tests may also be used. In her most recent
visit, Stacie’s scores were similar to the prior year’s findings,
with her scoring about 1.5 SD below the mean on most tasks.
Her grip and pinch strength were also around the 40th per-
centile for her age and gender.
Another role of the clinical specialist is to facilitate growth
in children’s ADL and IADL skill independence. Children
with spina bifida have different timing and patterns of skill
development that often need specific advice and the use of
adaptive methods and devices.14,41 For example, the clinical
specialist may provide advice on techniques to manage
orthotic and other devices, methods to develop wheelchair
skills, and strategies to promote independence in bladder and
bowel care programs. Stacie managed most of her personal
care and participated in a few chores at home. The occupa-
tional therapist suggested that she and her family select
clothes to be worn to school the night before and recom-
mended purchasing clothes without fasteners or with a zippers
and snaps. Clinical follow-up emphasized health monitoring,
health promotion, and increasing her independence and par-
ticipation as she transitioned to middle school.
Residential or intensive day treatment programs characterize
another form of outpatient pediatric rehabilitation service.
These extended care programs focus on direct assistance with
community re-entry and participation. Simulated or actual
environments become the training sites for skills that enable
community participation and effective performance toward
goals of independent living, education, and work activities.
Summary
The provision of occupational therapy services to children
in hospitals is a specialized and challenging area of practice.
Occupational therapists in hospitals must have a thorough
understanding of the characteristics of health care systems, the
factors and trends that affect hospitals, including legal and
accreditation requirements, and the specialized needs of hospi-
talized children and their families. To achieve health and
functional goals, the occupational therapist must also under-
stand the roles of other professionals involved in the care of
children. Occupational therapists who are employed in hospi-
tals have the opportunity to gain expertise in assessment and
intervention of children of various ages, with many different
diagnoses, often within a dynamic, fast-paced environment. As
hospitals broaden their range of services in response to a chang-
ing health care system, hospital-based occupational therapists
724 SECTION IV Areas of Pediatric Occupational Therapy Services

will have opportunities to broaden their areas of expertise,
apply different models of service delivery, and develop new
practitioner roles.
• Hospital-based pediatric therapy services play a unique role
in the overall management of children and adolescents with
a new or chronic disability.
• In addressing acute and chronic problems, the occupational
therapist’s emphasis is on function and participation in life’s
events at home, at school, and in the community.
• New and established impairments and disabilities pose risks
for further complications, which necessitate a prevention
prioritization through subacute, acute, and outpatient or
ongoing rehabilitation interventions.
• Medical services follow policies and regulations imposed by
accreditation and regulatory agencies and third-party payers.
Collaboration with caregivers, school personnel, and
community-based practitioners is critical to effective interven-
tion and transition from hospital to home.

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Mathews, M. D., & Alexander, M. A. (Eds.),
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