Preparation of physical therapists to work with handicapped infants and their families: current status and training needs.

Preparation of Physical Therapists to Work with Handicapped Infants and Their Families: Current Status and Training Needs The need for physical therapists prepared to work with handicapped infants and their families has increased in the past two decades as early intervention programs have proliferated and as professionals have recognized that unique skills are needed to work with this population. With the growing demand for physical therapists in early intervention, the need for an increased focus in training in infant and family topics at all educational levels is evident. In 1979, the Section on Pediatrics of the American Physical Therapy Association identified competencies in pediatrics that should be included in entry-level programs. [1] Current APTA accreditation standards, however, minimally address the adaptation of general competencies to the pediatric patient, requiring only that entry-level curricula include learning experiences leading to competence in the application of "developmental activities." [2] Post-professional master's degree and doctoral programs in physical therapy are accredited by individual universities or regional accrediting agencies, and advanced-level competencies in pediatrics have been developed within the profession. [3] The current status of entry-level and advanced training of physical therapy students in content areas related to infants and their families, however, is not well documented.

The recent passage of Public Law 99-457, an amendment to the Education of the Handicapped Act extending mandatory public school services to 3- and 4-year-old children with handicaps, will undoubtedly accelerate the need for adequately trained physical therapists. All states have elected to participate in optional Part H, the section of the law that describes services to be made available to handicapped infants and toddlers from birth to age 36 months and to their families. Public Law 99-457 requires that services for children in this age group be designed to meet developmental needs and may include physical therapy as well as other related services. Early intervention for this age group must include a multidisciplinary assessment, a written Individualized Family Service Plan (IFSP) developed by a multidisciplinary team including the parents, and case management services for every eligible child and her or his parents.

The specifications of PL 99-457 present challenges to academic and clinical faculty members in the preparation of physical therapists to work with handicapped and at-risk infants and their families. The field of early intervention is evolving from discipline-specific, child-centered services to a family-oriented context within which professionals from many disciplines address the educational, medical, psychological, and therapeutic needs of handicapped infants and their families. Students require instruction not only in areas related to direct patient care but also in effective work with other professionals and families to provide coordinated services. Documentation of the most effective procedures and materials for educating physical therapists to work in an interprofessional context with this population is warranted.

In response to the need for research on effective training of professionals to work with handicapped infants and their families, the US Department of Education funded the Carolina Institute for Research on Infant Personnel Preparation (CIRIPP) at The University of North Carolina at Chapel Hill. The Institute's purposes are to develop and evaluate needed training materials and curricula and to evaluate methods for educating physical therapists and other professionals to meet the needs generated by the new legislation. Institute faculty members from eight disciplines (nursing, nutrition, occupational therapy, physical therapy, psychology, special education, speech and language pathology, and social work) conducted research in preparation for materials and curricula development. The purpose of this article is to present research activities undertaken by physical therapy faculty members to 1) describe the current content in entry-level and postprofessional physical therapy curricula on infant- and family-related topics, 2) determine the need for training materials and curricula in content areas related to infants and families, and 3) identify priorities for development and evaluation of new or improved training materials and curricula.

Method

Survey

A telephone survey of educational programs in the eight disciplines identified in the preceding paragraph was developed and conducted by the CIRIPP faculty from March 1988 to November 1988 to gather data in five areas: 1) amount of exposure students receive in infant development, assessment, and intervention; family assessment and intervention; interdisciplinary team process; case management; and values and professional ethics; 2) availability of clinical experiences with infants and their families; 3) availability of training in specialty areas; 4) availability of infant-family specialization; and 5) plans for increasing infant-family focus in the future. Ninety-six physical therapy programs were contacted in the telephone survey. All postprofessional master's degree programs (N = 30) and all doctoral programs (N = 9) [4] were contacted to identify those offering infant-family specialization. Entry-level programs offered by schools with postprofessional programs were also included in the survey (19 baccalaureate, 12 entry-level master's degree). To increase the sample size of entry-level programs, a random sample of 26 physical therapy programs in schools with entry-level programs only [5] was contacted (23 baccalaureate, 3 entry-level master's degree) for a total of 42 baccalaureate and 15 entry-level master's degree programs. Preliminary telephone contacts were made with each program to identify faculty members responsible for pediatric or infancy content in the curriculum. Identified faculty members were then contacted by telephone by the second author (BGF) to complete the survey. A closed-end questionnaire developed by the CIRIPP multidisciplinary faculty was prompted by a computer program, and responses were entered directly into the computer during the telephone contact.

A second questionnaire was developed by two of the authors (CGC and IJW) and was mailed to those physical therapy schools identified by the telephone survey as offering an infancy specialization or an infancy-family focus (n = 23). Respondents were requested to report 1) demographic information, 2) program objectives, 3) competencies developed in the program, 4) contact hours of specific course content related to infants and families, 5) information on clinical experiences, 6) research requirements, and 7) information regarding perceived need for training materials in specific content areas.

Working Conference

In May 1988, the CIRIPP conducted a 3-day working conference with prominent professionals from each of the eight disciplines in addition to representatives from audiology and medicine. Participants included 10 physical therapy faculty members and representatives of the APTA currently involved in the preparation of physical therapy students to work with infants and their families. Conference participants were first requested to define the primary mission and major roles of physical therapists working with handicapped and at-risk infants and their families. Using a nominal group procedure, conferees then listed and ranked suggestions for integrating content of infancy-focused training in entry-level physical therapy programs, suggestions for materials and curricula development, and key research issues in personnel preparation.

Data Analysis

Data from the telephone surveys were analyzed using descriptive statistics. Analyses of the mail surveys consisted primarily of calculating frequency distributions, ranges, and measurements of central tendency.

Results

Surveys

Telephone survey. Surveys of 73 physical therapy programs were completed for a response rate of 76%. The respondents consisted of 33 baccalaureate programs (79%), 13 entry-level master's degree programs (87%), 22 postprofessional master's degree programs (73%), and 5 doctoral programs (56%). Facultury members in four institutions offering a total of 8 physical therapy programs (8%) refused to complete the survey because of time constraints. Faculty members responsible for pediatric course content in 15 programs (16%) were unavailable for telephone contact during the months the survey was conducted.

Respondents reported the estimated number of clock hours that all students in the program receive in topics related to infants and their families. More than 93% of the entry-level programs surveyed included course content in normal infant development, abnormal infant development, infant assessment, and infant intervention (Tab 1). Content related specifically to infants was typically incorporated into pediatric of life-span development courses, and the number of clock hours varied widely, ranging from 0 to 50 hours. Students in 22 baccalaureate programs (67%) and 10 entry-level master's degree programs (77%) received exposure to family assessment. Eighteen baccalaureate programs (55%) and 8 entry-level master's degree programs (62%) included family intervention in their curricula. The number of clock hours devoted to family assessment and intervention varied widely with a mean of less than 6.5 hours (Fig 1).

Thirty-two baccalaureate programs (97%) and 12 entry-level master's degree programs (92%) provided opportunities for students to gain clincial experience with handicapped or at-risk infants in the laboratory sections of their regular course work (Fig 2). These experiences were required in 27 baccalaureate programs (84%) and all of the entry-level master's degree programs. Only 12 of the baccalaureate programs (36% and 3 of the entry-level master's degree programs (23% provided opportunities for students to have clinical experience with families of handicapped infants as part of regular course work (Fig 2), and these opportunities were required in 4 of the baccalaureate programs and 2 of the entry-level master's degree programs. When not required, only 28% of the students in baccalaureate programs and 10% of the students in entry-level master's degree programs elected these experiences each academic year.

Thirteen baccalaureate programs (41%) and 11 entry-level master's degree programs (85%) provided opportunities for students to concentrate in particular areas of study. Among these programs, 6 baccalaureate and 6 entry-level master's degree programs offered students opportunities to focus on work with infants. Of those programs not offering infancy specialization, 12 baccalaureate programs (44%) and 6 entry-level master's degree programs (86%) indicated that an infancy focus or specialization would not be made available in their programs within the next five years. The most frequently mentioned factors precluding a stronger infancy focus were lack of curriculum flexibility (54%) and inconsistency with program mission (28%). Lack of faculty interest or expertise was not an issue, as 86% of all programs reported having faculty members who have a clear area of expertise in infancy.

Twenty postprofessional master's degree programs surveyed (91%) offered opportunities for infancy specialization. In the doctoral programs surveyed, only three graduates had specialized in infancy in the past 5 years.

Seventy-two percent of the respondents from entry-level and postprofessional programs indicated a need for training materials in physical therapy for working with handicapped or atrisk infants, and 87% indicated a need for training materials for working with infants' families. When respondents were asked if they would include additional material on handicapped infants and their families in their curricula, if available, 76% indicated that they would include self-study computer materials and 59% indicated that they would use 1-hour and 3- to 6-hour lecture materials. Fewer than 37% indicated they would include a course module lasting 3 to 6 weeks or a course lasting one term.

Mail Survey. Fourteen responses were received from physical therapy school offering infancy-family specializations, a return of 61%. Respondents reported the existence of a total of 19 infancy subspecialization options. Seven were in entry-level programs, 9 in postprofessional master's degree programs, 2 in doctoral programs, and 1 in a nondegree (fellowship) program. Respondents from schools offering infancy specialization at two educational levels (n = 5) did not report differences between the educational levels in program format, course offerings, clinical experience, or need for training materials. Infancy specialization varied in form among programs and included major tracks (2 programs), minor or supporting areas (4 programs), interest areas (7 programs), elective course work (8 programs), and clinical practicum (7 programs). Students electing infancy specialization spent an average of 8 months in formal course work and clinical experience with infants and their families. Twelve programs were supported in part or solely by tuition and internal funds, and 6 programs received federal training grant funds.

The primary objectives of the entry-level programs were to prepare generalists with basis competencies in infant and family management (100%). Three entry-level programs (43%) reported competencies developed in interdisciplinary team practice.

The primary objectives of postprofessional programs were to prepare pediatric leaders (89%), to enhance infant-management skills of experienced pediatric therapists (89%), and to prepare clinical researchers (67%). In seven postprofessional programs (78%), competencies reportedly wre developed in advanced clinical skills and in resarch skills. Six postprofessional programs (67%) reported competencies developed in interdisciplinary team process.

The number of clock hours of instruction in specified content areas related to work with infants and their families in entry-level and postprofessional programs is presented in Table 2. Three programs reported that clock hours in some content areas varied to meet students' needs, and one respondent did not report numerical values. Emphasis was placed on instruction in infant sensorimotor or neuromotor intervention with an average of 31 clock hours offered in 10 programs (71%) and on neonatalinfant screening and assessment with an average of 18 hours provided in 11 programs (79%). Only 4 programs (29%) reported instruction in family systems theory, and only 6 programs (43%) reported clock hours in parent-infant interaction assessment and intervention.

Eleven programs (79%) included clinical experience with a mean of 130 required clinical hours (range = 6-320 hours). An average of 48% of the clinical experience was spent on infant assessment, and an average of 38% was spent on infant intervention. An average of 13% of the clinical experience was spent on the interdisciplinary team approach to patient care. No more than 10% of the clinical experience was spent on family assessment, communication with families, or case management.

Nine survey questions related to the perceived need for development of infancy- and family-related training materials and curricula (Tab 3). Areas perceived in greatest need for materials were family assessment, communicating with families, and case management. Eighty-six percent of the respondents indicated they would use well-documented case studies in these content areas in combination with instructor training materials if these materials were available.

Working Conference

Working conference participants met in discipline-specific and interdisciplinary groups. The results of four discipline-specific activities are presented in this article.

First, conference participants identified the primary mission and major roles of the physical therapist working with handicapped and at-risk infants and their families. mission and role statements were developed and presented by the first author (CGC), then modified by the group. The following statement was accepted by the participants as the primary mission of the physical therapist working with handicapped or at-risk infants and preschool-aged children and their families:

To enhance the sensorimotor development, neurobehavioral organization, and cardiopulmonary status of handicapped or at-risk infants and preschool-aged children within a family and community context.

The conference participants reached consensus on 13 major functions of the physical therapist working with infants and preschool-aged children and their families: 1) screening for neuro-musculo-skeletal, and cardiopulmonary, and general developmental dysfunction; 2) assessing children's neuro-musculo-skeletal status and motor skills for differential diagnosis; 3) assessing children's cardiopulmonary status; 4) designing, implementing, and monitoring therapeutic interventions; 5) evaluating intervention effectiveness and modifying programs as needed; 6) identifying with the family their strengths, priorities, and needs; 7) developing family recommendations and monitoring their implementation; 8) participating in interdisciplinary planning; 9) consulting with the family members and care givers; 10) consulting with and referring to other professionals and community agencies; 11) serving as case managers; 12) recommending or fabricating adaptive equipment and mobility devices; and 13) recommending or implementing environmental modifications.

Second, conference participants reviewed preliminary telephone and mail survey results and generated a list of content areas for working with infants and their families recommended for inclusion in entry-level physical therpay curricula. Eight broad content areas were identified and ranked in order of importance: 1) family-focused topics including family dynamics, family systems theory, and cultural and economic variations in family patterns; 2) case management including the role of the case manager, community resources, and patient and family advocacy; 3) life-span issues including transitions, crisis intervention, and normal and abnormal development with integration across developmental domains; 4) communication style with team and families including team process and interprofessional competencies; 5) federal laws including PL 99-457 and the development of IFSP; 6) treatment of the child through the family; 7) issues related to prevention of dysfunction; and 8) selection criteria for standardized assessment. Methods to integrate content changes into entry-level physical therapy curricula were recommended and included requiring courses with family-related content prior to entry into physical therapy programs, incorporating units on families within development-pediatrics courses, incorporating life-span issues into many courses, recognition by program directors of the need for content change, and inclusion of infancy content and content on PL 99-457 including the IFSP on licensure examinations.

The group then generated specific recommendations for training materials and curricula development targeted to the integration of infant- and family-related content into physical therapy programs. The following six recommendations were listed and ranked in order of importance: 1) development of videotapes on realistic case studies; 2) development of small packages on case management and federal laws and development of an IFSP for integration into current curricula; 3) development of a centralized loan library of videotapes, computer programs, and assessment tools; 4) development of families' participation during classes for open discussions and participation in parent-to-parent training; 5) development of guidelines for clinical instructors to encourage incorporation of family issues into clinical rotations; and 6) modeling of home programs and parent-therapist interactions by educators.

Finally, participants were asked to identify key research issues in the preparation of physical therapists to work with handicapped and at-risk infants and their families. A list of 12 research questions was developed and rank ordered by participants (Tab 4). Recommended research topics included professional competencies needed to work with handicapped and at-risk infants and their families, recruitment of physical therapists into pediatrics, and effective models of academic and clinical education to prepare physical therapists to work in early intervention settings.

Discussion

Results of the surveys must be interpreted with caution because respondents reported difficulty in accurately estimating the clock hours spent on course content related specifically to infants and toddlers and their families. Course content on infants from birth to age 3 years was commonly reported to be incorporated into pediatric content covering topics that relate to infants, children, and adolescents. Many issues related to infants and their families, however, are unique to this population. [6] Despite the limitations of the survey methodology, the telephone survey results, in conjunction with those of the mail survey and the working conference, did provide data regarding the preparation of physical therapists to work with young children and their families. These data will be discussed as they relate to 1) the current status of preparation of entry-level physical theraphy students to work with infants and their families, 2) the preparation of postprofessional master's degree students to assume roles as clinical specialists in early intervention, and 3) the need for infant- and family-focused training materials and curricula at the entry level and at the postprofessional master's degree level of education.

Students in entry-level physial therapy programs commonly receive some degree of instruction in topics related to infants. The number of clocks hours devoted to these topics, however, varies widely across programs. The survey results support the contention that the extent and quality of pediatric content in entry-level physical theraphy programs are highly variable. [7] Entry-level competencies unique to pediatric physical theraphy in the areas of evaluation, program planning, implementation, and documentation were identified by the APTA Section on Pediatrics in 1979. [1] The Commission on Accreditation in Physical Theraphy Education should be encouraged to incorporate pediatric competencies into the accreditation evaluative criteria for entry-level curricula to ensure adequate performance of graduates. In addition, physical theraphy educators in academic and clinical settings should be aware of entry-level pediatric competencies so that students can be adequately prepared for work with individuals of all ages.

Many students at the entry level receive minimal or no exposure to family-related topics and no clinical experience with families of handicapped and at-risk infants. When offered the opportunity to work with families of infants, few students elected these experiences, which may reflect time constraints or lack of interest. The change in health care toward family-centered services has important implications for physical therapy education. Students require instruction in appropriate and effective interaction with families as well as in direct-service provision. Increased exposure to families of children with special needs may help students recognize the concerns of this population. The majority of students are provided opportunities to work with handicapped infants as part of their regular course work, and guided activities such as interviews with the families of these infants could be incorporated into entry-level curricula with minimal additional time. In addition, clinical educators should model appropriate therapist-family communication and encourage interaction with families as part of clinical training.

Opportunities for students to specialize in or concentrate on infant- and family-related topics are not provided in most entry-level programs even though most programs have faculty members with the expertise to teach infancy content. This lack of opportunities undoubtedly reflects time constraints within physical therapy programs that must prepare professionals for a wide scope of practice. [8] Physical therapists must be prepared to treat individuals of all ages who have a variety of disabilities. Entry-level course content is rapidly expanding with the increased complexity of health care. [9] Many topics in physical therapy such as those related to families are applicable across the life span and should be incorporated into the curriculum from this perspective. Modifications of physical therapy intervention ncessary for the pediatric population could be addressed in many courses without the need for the student to "specialize" in pediatrics. Course content on case management, values, and professional ethics, for example, is commonly incorporated into many entry-level courses. Content and number of clock hours in these areas may be adequate for the entry-level curriculum, but specific examples relating to infants should be included to increase the students' knowledge of issues unique to this population.

The results of both surveys and the working conference suggested a substantial need for entry-level training materials and curricula related to infants and families and provided direction for the design of these materials and curricula. Survey respondents indicated a need for infancy-and family-focused training tools such as videotapes or self-instructional computer materials that could be easily incorporated into current curricula with minimal additional time. The greatest needs are for materials demonstrating various aspects of family issues including family dynamics and effective communication with families.

The objectives and curriculum design of postprofessional master's degree programs in physical therapy are different from those at the entry level. Training in certain clinical areas of physical therapy for infants, such as therapy in the neonatal intensive care unit, is not appropriate at the entry level and should be provided only at the advanced level (JK Sweeney, unpublished manuscript, 1986). [10,11] Sixteen advanced-level competencies have been recognized as necessary for clinical specialization in pediatrics. [3] Variability in pediatric course content among advanced-level programs may be appropriate in order to provide students narrowly focused clinical and research experience. Survey results, however, suggested that course content and clinical experience in the skills necessary to attain advanced clinical competence in areas such as communication with families and case management [3] were minimal in the majority of programs offering infancy specialization. Materials and curricula addressing research and clinical topics such as family assessment, communicating with families, family systems theory, and parent-child interaction need to be developed for advanced-level programs offering infancy subspecialization. Issues in case management are also high priorities for new materials.

The focus of this article is on entry-level and postprofessional physical therapy programs; however, the majority of clinicians gain pediatric knowledge and skills through clinical experience and various forms of continuing education. [7] Few students enter postprofessional programs each year, and certainly more students are needed to assume leadership roles.

The personnel shortage in physical therapy is one of the most important issues facing our profession, [9] and clinical specialists trained in postprofessional master's degree programs will be unable to satisfy the anticipated demand for professionals with expertise in early intervention. Continuing education courses, self-study courses, and fellowship programs in infant and family topics are options for increasing the availability of appropriately trained pediatric specialists. [7]

Research on the preparation of physical therapists to work with handicapped and at-risk infants and their families is clearly needed to identify and validate key professional competencies and fffective models of preservice and in-service education. New and existing training materials and curricula should be evaluated to document their effectiveness in preparing therapists to work within interdisciplinary teams delivering intervention services to infants and toddlers and their families.

Conclusion

The results of the telephone and mail surveys and the working conference provided useful data regarding the preparation of physical therapists to work with handicapped and at-risk infants and their families. Course work in family-related topics and clinical experiences with families were found to be minimal. The development of new infant- and family-focused training materials and curricula may help to adress the growing need for well-prepared physical therapists in early intervention.

References

[1] Pediatrics in Basic Physical Therapy Professional Education. Section on Pediatrics, American Physical Therapy Association; 1979

[2] Accreditation Handbook. Alexandria, Va: American Physical Therapy Association: 1989

[3] Physical Theraphy Advanced Clinical Competencies: Pediatrics. Board for Certification of Advanced Clinical Competence and Pediatric Specialty Council, Alexandria, Va: American Physical Therapy Association; 1985

[4] Educational programs leading to postgraduate degrees for physical therapists. Phys Ther. 1987;67:1627-1629

[5] Educational programs leading to qualifications as a physical therapist. Phys Ther. 1987;67:1623-1626

[6] McCollum JA. Early interventionists in infant and early childhood programs: a comparison of preservice training needs. Topics in Early Childhood Special Education. 1987;7(3):24-35

[7] Heriza CB, Lunnen KY, Fischer J, et al. Pediatric practice in physical therapy: a survey. Phys Ther. 1983;63:948-956

[8] Effgen SK. Preparation of physical therapists and occupational therapists to work in early childhood special education settings. Topics in Early Childhood Special Education. 1988;7(4):10-19

[9] Wilhelm IJ, ed. Proceedings of the Symposium on Priorities for Physical Therapy in Maternal and Child Health. Chapel Hill, NC: The University of North Carolina at Chapel Hill; 1988

[10] Campbell SK. Organizational and educational considerations in creating an environment to promote optimal development of high-risk neonates. Physical & Occupational Therapy in Pediatrics. 1986;6(3-4):191-204

[11] Competencies for the Physical Therapist in the Neonatal Intensive Care Unit (NICU). Educational Committee, Section on Pediatrics, American Physical Therapy Association; May 27, 1988

C Cochrane, MS, PT, was Clinical Assistant Professor, Division of Physical Therapy, Department of Medical Allied Health Professions, The University of North Carolina at Chapel Hill, Chapter Hill, NC 27599-7135, when this article was written. Address all correspondence to 30 Flemington Rd, Chapel Hill, NC 27514 (USA).

B Farley, MS, PT, is Clinical Research Assistant, St Joseph's Hospital and Medical Center, 350 W Thomas Rd, Phoenix, AZ 85001. She was a student in the master's degree program, Division of Physical Therapy, The University of North Carolina at Chapel Hill, when she Assisted with this study in partial fulfillment of hr degree requirements.

I Wilhelm, MS, PT, is Research Associate Professor, Division of Physical Therapy, The University of North Carolina at Chapel Hill.