Pediatric Physical Therapists Care the Health Status of Children with Special Needs
廖華芳 汪子瑄 潘懿玲 (Hua‐Fang Liao Tze‐Hsuan Wang Yi‐Ling Pan)
隨著發展科學(developmental science)日益全球化，幼兒生活情境在人類發展過程中的作用日益受到重視。專家指出，「早期介入」(early childhood intervention)不同於「早期介入服務」(early childhood intervention services)。「早期介入」是由主要照顧者，通常是家長，支持兒童在自然場域得到有意義的學習機會和經驗。「早期介入服務」是在法令政策規範下，早期介入專業人員提供服務給符合早期介入資格的兒童及其家庭，專業人員會支持家長在兒童生活場域或生活作息中持續發展學習。所以兒童早期介入是發生在兩次早期介入服務的期間。因此，早期介入越多越好，但早期介入服務則是依兒童及家庭的需求個別化提供，量不一定要多，但必須高品質有實證。這次的疫情比較會衝擊接受早期介入服務的時間和次數，但只要家長善用居家環境，調整好自己的心態，特殊需求兒童的早期介入未必會受到太大衝擊，反而有機會調整在居家環境的早期介入活動。
COVID 19 疫情爆發也讓我聯想到世界衛生組織於 2001 年提出的「生物心理社會模式」(biopsychosocial model)，活動和參與是健康情形和環境因素互動造成。對特殊需求兒童而言，新冠肺炎病毒導致的社交距離措施的環境因素，使兒童的戶外及社區活動和參與頻率及多樣性大量減少。既然是環境因素所造成，家長們也可改造環境因素來減少衝擊。建議家長一方面提升居家早期介入內容的頻率及多樣性，安排兒童在家庭中可參與的各種活動，讓兒童持續得到有意義的學習機會和經驗；另一方面設法減低無法參與戶外及社區的休閒運動及社會互動的不良影響。然而提升兒童早期介入品質最重要的因素，是家長的健康以及家庭的經濟及生活品質。因此，家長不要忘記將自己的身心健康先照顧好，也要讓自己有時間去做自己想做的事。
遊戲可促進發展和健康，即使因為疫情的關係，要待在家中，細心觀察幼兒玩耍，多一點時間和幼兒互動遊戲，可以發現遊戲中，兒童的動作、語言、認知和社會功能也跟著發展。「寓教於樂」的想法只能隱存於父母心中，實際陪伴幼兒遊戲時，要尊重幼兒出於內在動機的自由選擇，要跟隨幼兒喜歡的方式玩，再伺機輕鬆變通。當家長自己打從心底覺得好玩時，就會發現，原來遊戲的樂趣來自於互動過程本身，而不是非要學會什麼東西。大人只要喚醒自己愛玩的童心，每個父母都可以是孩子王。以下有一些在家裡安排遊戲活動的提示。開始盤點家中現有的玩具，將玩具列表，標記出喜歡或不喜歡，以及適合的發展年齡和場所。若幼兒年齡夠大，可以和他討論讓他選擇。對於比較小的幼兒，一次只拿出 1、2 樣玩具給幼兒玩，輪流在不同天玩不同的玩具，幼兒才不會玩膩。找到一些大人可以和幼兒一起玩得遊戲或是家中幾個兄弟姊妹可以一起玩的遊戲，當然幼兒可以獨立玩，也是一種能力。
Pediatric Physical Therapists Care the Health Status of Children with Special Needs under COVID-19 (20200414)
Hua‐Fang Liao Tze‐Hsuan Wang Yi‐Ling Pan
Has the Coronavirus disease (COVID-19) outbreak stopped early intervention for children with special needs? What can we do about it? In fact, as long as we follow current trends and concepts of early intervention, provide our children with learning opportunities and experiences in the natural living environment and adopt the principles and methods of home-based early intervention; the early childhood intervention will not be interrupted as worried, but can be more useful for the improved intensity and diversity. Parents or family members now have more time to accompany their children, to understand their advantages and needs, interact with them and guide their learning; parents can also help their children to learn various skills in real life, experience pleasure and sense of accomplishment from learning by making a more facilitating environment and activities and gradually reducing the degree of assistance or prompts.
With the increasing globalization of developmental science, the role of children's living context in human development is getting more attention. Experts point out that "early childhood intervention" is different from "early childhood intervention services". "Early intervention" is for the primary caregivers, usually the parents, to support their children to gain meaningful learning opportunities and experiences in the natural environment. "Early intervention service" indicates the services for children and families who meet the qualifications for early intervention, provided by the early intervention professionals under the regulations of laws and policies. The professionals support parents to help their children continue to develop and learn from daily routines in natural settings. In fact, the early childhood intervention occurs between two early intervention services. Therefore, the more intervention, the better, but the early intervention services should be highquality, not quantity, supported by substantial empirical evidence, and the services should be provided according to the individual needs of children and families. This epidemic will affect the time and frequency of receiving early intervention services. However, as long as parents make the best use of the home environment and keep a positive attitude, the early intervention of children with special needs may not be limited. Instead, it may be a turning point to change the intervention at home in a better direction.
The outbreak of the COVID 19 epidemic also reminded me of the "biopsychosocial model" proposed by the World Health Organization in 2001. Activities and participation are caused by the interaction between health conditions and environmental factors. For children with special needs, the environmental factors of the social distancing caused by the pandemic have significantly reduced the diversity of outdoor and community activities and frequency of participation for children. Since the environmental barriers caused the restriction of participation, parents can reduce the impact by modifying the environment.
We recommend that on the one hand, parents increase the frequency and diversity of homebased early intervention, arrange various activities that children can participate at home so that children can continue to receive meaningful learning opportunities and experiences. On the other hand, try to reduce the negative impact of unable to participate in leisure activities and social interaction in the community. However, the most important factors for improving the quality of early childhood intervention are the health of the parents and the economic and quality of life of the family. Therefore, parents should not forget to take care of their physical and mental health first, but also allow themselves time to do what they want to do.
Routines-based early intervention emphasizes the integration of goals of early intervention plan into family daily routines, using existing resources in the family context for children exploration and learning, allowing young children to respond to natural prompts, and repeating exercises in a real-life situation. Therefore, the daily activities of infants and young children have become a part of young children's learning, and parents should take the initiative to propose to professionals and learn how to integrate early intervention into their daily routines.
Play and self-care are routines, and also essential content of the early intervention. Playing can promote development and health. Even if you are staying at home because of the epidemic situation, you can carefully observe the children's playing behavior and spend more time playing and interact with them. You will find that the children's motor, language, cognitive, and social functions develop through playing. The idea of " fun and educational" can only be hidden in the minds of parents. When playing with children, they must respect the children's choices based on their internal motivations, follow children’s lead, and modify accordingly. When parents feel fun from the bottom of their hearts, they will find that the real joy of playing comes from the interactive process itself, rather than having to learn something. As long as adults arouse their childlike innocence, every parent can be a playful child. Here are some tips for arranging playing activities at home. You can start with checking toys in your home, making a list, mark likes or dislikes, and the matching developmental age and place. If the child is old enough, you can discuss it with him/her to let them choose. For relatively young children, only one or two toys are given at a time and playing different toys on different days in turn so that the children will not be bored. Design games that adults can play with young children or for siblings playing together at home; games that can be played alone are good, too, for it is an ability for young children to play independently.
Self-care is not just a skill training, its development needs the support of many other developmental skills. To develop the self-care ability of children, firstly, parents must find and create opportunities for children to participate in daily life, and accumulate enough successful experience before the caregivers can let go and let the children be independent. Self-care is not just a skill to take care of oneself. Young children can acquire various abilities in participating in self-care activities. For example, having meals can integrate a variety of skills according to different ages. Such as moving to the dining room, sitting on the chair, learning table manners, using a variety of food utensils suitable for his or her age, learning the names of food and related knowledge, talking with family members about what happened during the day to enhance familial relationships, and even help preparing and clean up before or after meals.
Regular exercise can enhance the immunity of children and reduce the risk of infection. If the situation permits, find an outdoor space which is less crowded and with fresh air to do some leisure activities. To prevent the infection, during the epidemic, try not to let young children join group activities, and do not touch the equipment in playgrounds. Instead, doing activities that can be carried out individually, such as hiking, cycling/ scootering, and climbing. For playing ball with family, try to dribble, kick, throwing, and catching to avoid physical contact or combat with others. Clean your hands and sports equipment after exercise. When returning home from the outdoors, be sure to wash your hands and change clothes. If the home environment is available, try to allow young children to have physical play or physical activities at home for a period of time. You can turn on the music, let the children dance and sing along with the melody, or put a mattress on the floor, let the children run or do soft exercises on it, or use the sheets to play peekaboo with infants, or camping in the living room. You can also use somatosensory game machines to exercise with young children at home to increase physical fitness. Sports videos on the internet are also useful resources, and you can do parent-child yoga or rhythm and gymnastics with the videos. There are also many online resources in Taiwan provided by the Wang Zhanyang Social Welfare Charity Foundation, such as information about physical games and gross motor activities from the "Let the young children move- Magic Book of Health and Fitness for Slow Flying Angels -Teacher's Manual" and "Smart Moves, Smart Brains". You can register for the free membership and download the books online (http://www.wjy.org.tw/j20r/Cc1a00.do). This outbreak let everyone realize the needs of tele-intervention services for children with special needs. Parents can ask your early treatment team or unit, whether there is tele-intervention or distance learning related services, so that the early intervention team can continue to support families to provide children with learning opportunities and experiences.
When arranging or doing activities with young children, be sure to pay attention to their mastery motivations. As long as the children are motivated, they will actively participate in the activities, thus increasing the opportunities for repeated manipulation and interaction with toys, teaching materials, and people, resulting in better development. Mastery motivation refers to the inherent, multi-faceted psychological force of children, as that stimulates children to attempt, in a focused and persistent manner, to solve a problem or master a skill or task which is at least moderately challenging for him or her. Young children rely on mastery motivation to solve problems, learn skills to complete the task. Here are some strategies to improve mastery motivation of young children: 1) Arrange the toys, environment or activities that the child likes and with moderate difficulty so that the child has a successful and enjoyable experience; 2) Support and encourage the child to try more challenging activities independently. Although he/she may not be able to complete the activity successfully, parents should not give too much assistance too quickly; 3) Encourage children to develop the motivation to try independently, to develop their ideas of play, and to explore the environment freely, to avoid excessive assistance or guidance from adults; 4) The adults should be sensitive and responsive: when children play toys or perform activities, give appropriate and timely assistance to help young children to succeed. Through timely guidance from parents, the ability of young children can be improved. For example, when the child is beading, if the parent understands that the child’s eyehand or bimanul coordination is not good enough, he/she can help stabilize the front end of the thread and let the child practice aligning the beads and inserting them into the end of the thread, or providing beads with larger holes and harder strings to make the child have more successful experiences; 5) Praise and encourage young children the attempt to try challenging activities, do not praise them only when they succeed, so that children will be more willing to try different things and will be more motivated to learn difficult tasks.