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Family-centered care on a physiotherapy course: case reports

Abstract

Introduction:

Family-Centered Care (FCC) is a philosophy that recognizes the family as a partner in the intervention process and currently constitutes one of the most important practices in pediatric physical therapy intervention. For this reason, FCC should be part of pediatric physiotherapy training so that future physiotherapists are able to include it in their clinical practice.

Objective:

To verify the feasibility of applying FCC as part of an undergraduate Physiotherapy course, focusing on the activity of children with different health conditions.

Methods:

This is a case report, based on information collected from medical records, on an intervention program carried out with 5 children and their families, in the home, once a week for seven weeks, by students of physical therapy in pediatrics. For pre- and post-intervention assessment of the children, standardized instruments were used: Gross Motor Function Measure (GMFM) and the Alberta Infant Motor Scale (AIMS). Reports were collected from families and students regarding the FCC experience.

Results:

The children with neurological impairment increased the GMFM target area score by more than 5%, indicating clinical improvement. A child at biological risk had a pre-intervention AIMS percentile of < 25 and a post-intervention percentile of 50, while another child with developmental delay did not alter his percentile. At the end of the intervention, families reported greater confidence in carrying out activities with their children and students reported the experience as relevant to their professional training.

Conclusion:

The practical application of FCC proved promising in the academic context of pediatric physical therapy.

Keywords:
Child; Family; Higher education; Physiotherapy

Resumo

Introdução:

O Cuidado Centrado na Família (CCF) é uma filosofia que reconhece a família como parceira no processo de intervenção e, atualmente, constitui uma das práticas mais importantes na intervenção fisioterapêutica pediátrica. Por este motivo, o CCF deveria fazer parte da formação em fisioterapia pediátrica de maneira que futuros fisioterapeutas pudessem inseri-lo em sua prática clínica.

Objetivo:

Verificar a viabilidade da aplicação do CCF em uma disciplina de graduação em fisioterapia, com foco na atividade de crianças com condições de saúde variadas.

Métodos:

Trata-se de um relato de casos, a partir de informações coletadas em prontuários, sobre um programa de intervenção realizado com cinco crianças e suas famílias no contexto domiciliar, uma vez por semana, durante sete semanas, por discentes da disciplina de fisioterapia em pediatria. Para a avaliação pré e pós-intervenção das crianças, utilizaram-se instrumentos padronizados: Avaliação da Função Motora Grossa (GMFM) e Escala Motora Infantil de Alberta (AIMS). Foram coletatos relatos das famílias e discentes quanto à experiência com o CCF.

Resultados:

As crianças com comprometimento neurológico aumentaram a pontuação na área-meta do GMFM em mais de 5%, indicando melhora clínica. Uma criança de risco biológico apresentou AIMS percentil pré de < 25 e pós de 50, enquanto outra criança com atraso no desenvolvimento não alterou seu percentil. Ao final da intervenção, as famílias relataram maior confiança na realização de atividades com suas crianças e os discentes relataram a experiência como relevante na formação profissional.

Conclusão:

A aplicação prática do CCF mostrou-se promissora no contexto acadêmico da fisioterapia pediátrica.

Palavras-chave:
Criança; Família; Ensino Superior; Fisioterapia

Introduction

The context in which the child is inserted and their interpersonal relationships, especially those established with their parents and other family members, have a significant impact on their development.11 Bronfenbrenner U, Morris PA. The ecology of developmental processes. In: Damon W, Lerner RM (Orgs.). Handbook of child psychology: Theoretical models of human development. New York: John Wiley; 1998. p. 993-1028. The presence of a child with atypical development influences the entire family routine and is often accompanied by feelings of guilt, vulnerability, and incapacity on the part of the family.22 Grossi FS, Crisostomo KN, Souza RS. Vivências de mães de filhos/as com deficiência: uma revisão sistemática. Higia. 2016;1(2):134-47. Full text link
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Therefore, recognition of the family’s value and their insertion in the care of the child contributes to recognizing their capabilities, favoring family empowerment, and, consequently, generating greater confidence in facing daily adversities. Thus, the physical therapy intervention should consider these aspects, understanding that the family is of central importance to the child's life.

In recent decades, a philosophical shift in care has been taking hold that “recognises the family as central to the child's life, sees the child in the context of his (unique) family, and supports family members in their role as caregivers”.33 Rosenbaum P, King S, Law M, King G, Evans J. Family-centred service: A conceptual framework and research review. Phys Occup Ther Pediatr. 1998;18(1):1-20. DOI
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Such a philosophy of care is known as Family-Centered Care (FCC). FCC is currently the most important practice in a pediatric physical therapy intervention program, being considered the approach which best contributes to children receiving comprehensive care, since childcare is included in the family's daily routine. In addition, collaboration between parents and therapists enables a more effective behavior plan.44 An M, Palisano RJ. Family-professional collaboration in pediatric rehabilitation: a practice model. Disabil Rehabil. 2014;36(5):434-40. DOI
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,55 Law M, Darrah J, Pollock N, King G, Rosenbaum P, Russell D, et al. Family-centred functional therapy for children with cerebral palsy. Phys Occup Ther Pediatr. 1998;18(1):83-102. DOI
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FCC is in line with the biopsychosocial model of the International Classification of Functioning, Disability, and Health (ICF),66 Organização Mundial da Saúde. Classificação Internacional de Funcionalidade, Incapacidade e Saúde. Versão para Crianças e Jovens. São paulo: Edusp; 2011. 312 p. in which functionality/disability is related not only to the health condition, but is also based on the perspective of the individual's body and society, that is, in the domains of body structure and function, activity, and participation; it is the result of the dynamic interaction between these components and contextual factors (environmental and personal).66 Organização Mundial da Saúde. Classificação Internacional de Funcionalidade, Incapacidade e Saúde. Versão para Crianças e Jovens. São paulo: Edusp; 2011. 312 p. Therefore, being central to the child's life, the family provides an important environment for the child and represents a central contextual factor.77 Rosenbaum P, Gorter JW. The ´F-words´ in childhood disability: I swear this is how we should think. Child Care Health Dev. 2012;38(4):457-63. DOI
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An early-intervention physical therapy program, which has FCC as one of its basic premises, found positive results both for the child and their family.88 Hielkema T, Hamer EG, Boxum AG, La Bastide-Van Gemert S, Dirks T, Reinders-Messelink HA, et al. LEARN2MOVE 0-2 years, a randomized early intervention trial for infants at very high risk of cerebral palsy: neuromotor, cognitive, and behavioral outcome. Disabil Rehabil. 2020;42(26):3752-61. DOI
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,99 Hielkema T, Blauw-Hospers CH, Dirks T, Drijver-Messelink M, Bos AF, Hadders-Algra M. Does physiotherapeutic intervention affect motor outcome in high-risk infants? An approach combining a randomized controlled trial and process evaluation. Dev Med Child Neurol. 2011;53(3):e8-15. DOI
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The authors found that, months after completing the intervention, the infants who had been undergoing the FCC program showed better functional skills, assessed by the Pediatric Evaluation of Disability Inventory (PEDI), when compared with the group that had received traditional physical therapy (child-centered).88 Hielkema T, Hamer EG, Boxum AG, La Bastide-Van Gemert S, Dirks T, Reinders-Messelink HA, et al. LEARN2MOVE 0-2 years, a randomized early intervention trial for infants at very high risk of cerebral palsy: neuromotor, cognitive, and behavioral outcome. Disabil Rehabil. 2020;42(26):3752-61. DOI
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In addition, in another study by the same group, the authors found improved outcomes over time in the children of families using coping and care strategies within the context of FCC.99 Hielkema T, Blauw-Hospers CH, Dirks T, Drijver-Messelink M, Bos AF, Hadders-Algra M. Does physiotherapeutic intervention affect motor outcome in high-risk infants? An approach combining a randomized controlled trial and process evaluation. Dev Med Child Neurol. 2011;53(3):e8-15. DOI
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In Brazil, however, clinical physiotherapeutic approaches remain predominantly focused on the child's developmental changes and disabilities,1010 Marini BPR, Lourenço MC, Barba PCSD. Systematic literature review on models and practices of early childhood intervention in Brazil. Rev Paul Pediatr. 2017;35(4):456-63. DOI
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with child-centered interventions being practiced, with little family participation.1111 Bolsanello MA. Concepções sobre os procedimentos de intervenção e avaliação de profissionais em estimulação precoce. Educ Rev. 2003;(22):343-55. DOI
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Brazilian studies making use of FCC within the physiotherapy context are scarce.1212 Núcleo de Tratamento e Estimulação Precoce. Atenção a crianças com síndrome congênita do zika vírus: relato da experiência de uma abordagem centrada na família. Fortaleza: NUTEP; 2017. 46 p.

Thus, considering the importance of FCC, this philosophy of care should be part of the syllabus of physiotherapy courses in the area of pediatrics. The pediatrics section (SoP) of the American Physical Therapy Association highlights FCC in the provision of child health care as one of the essential skills, that is, it is considered as basic knowledge for all graduates in physical therapy.1313 Rapport MJ, Furze J, Martin K, Schreiber J, Dannemiller LA, DiBiasio PA, et al. Essential competencies in entry-level pediatric physical therapy education. Pediatr Phys Ther. 2014;26(1):7-18. DOI
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It is believed that one of the ways to incorporate FCC into Brazilian pediatric physical therapy would be to offer this content on undergraduate curricula, enabling future physical therapists to make use of FCC in their clinical practice. Thus, the objective of the present study was to verify the feasibility of applying FCC as part of an undergraduate physiotherapy course, focusing on the activity of children with different health conditions.

Methods

This is a quantitative and qualitative, retrospective, descriptive case report, carried out in the second half of 2018, based on information and data extracted from the medical records of patients in the pediatric discipline of the physiotherapy course of the Universidade Federal dos Vales do Jequitinhonha e Mucuri (UFVJM). The study was approved by the Research Ethics Committee of UFVJM, decision 4.005.807/CAAE 30291920.8.0000.5108.

The study participants were three children with cerebral palsy being treated at a school physical therapy clinic, but without clinical evolution in the previous year, in addition to a child with developmental delay and another at biological risk, both of whom were on the waiting list.

Standardized assessment instruments were used to verify the result of the physical therapy intervention through FCC according to the health condition: Alberta Infant Motor Scale (AIMS) and the Gross Motor Function Measure (GMFM).

The AIMS is a scale validated for the Brazilian population, with adequate psychometric measures,1414 Saccani R, Valentini NC. Análise do desenvolvimento motor de crianças de zero a 18 meses de idade: representatividade dos ítens da Alberta Infant Motor Scale por faixa etária e postura. Rev Bras Crescimento Desenvolv Hum. 2010;20(3):711-22. Full text link
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which assesses the gross motor skills of children from zero to 18 months of age. It consists of 58 items, divided into four subscales, described in the following postures: prone (21 items), supine (9), sitting (12), and standing (16). During the test, the evaluator observes the child's movement in the four positions and marks those observed and not observed. For each item observed, the child receives 1 point and for items not observed, the child receives zero. The items observed in all positions are added together, resulting in a total raw score varying from 0 to 58 points, which is later converted into the percentile of the child's motor development compared to children of the same age.1515 Pipper M, Darrah J. Motor assessment of the developing infant. St. Louis, MO, USA: Elsevier; 2021. 288 p.

For children with cerebral palsy, the standardized GMFM scale was used,1414 Saccani R, Valentini NC. Análise do desenvolvimento motor de crianças de zero a 18 meses de idade: representatividade dos ítens da Alberta Infant Motor Scale por faixa etária e postura. Rev Bras Crescimento Desenvolv Hum. 2010;20(3):711-22. Full text link
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referenced by criterion, and officially translated into Portuguese.1515 Pipper M, Darrah J. Motor assessment of the developing infant. St. Louis, MO, USA: Elsevier; 2021. 288 p. Version 88 was chosen because it has more items in supine and prone, and is, therefore, more suitable for children with severe gross motor function impairment. The GMFM is a system for assessing gross motor function over time or in response to an intervention, which is widely used in clinical practice in Brazil and in research work.1414 Saccani R, Valentini NC. Análise do desenvolvimento motor de crianças de zero a 18 meses de idade: representatividade dos ítens da Alberta Infant Motor Scale por faixa etária e postura. Rev Bras Crescimento Desenvolv Hum. 2010;20(3):711-22. Full text link
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,1515 Pipper M, Darrah J. Motor assessment of the developing infant. St. Louis, MO, USA: Elsevier; 2021. 288 p. The GMFM-88 consists of 88 items divided into five dimensions: a) lying down/rolling over; b) sitting; c) crawling/kneeling; d) standing; and e) walking/running/jumping. Through observation, each item is scored from 0 to 3: 0 - child does not initiate movement; 1 - initiates the movement but does not complete it (performs less than 10% of the movement); 2 - partially completes the movement (10% to less than 100%); and 3 - completes the movement. The score for each item is added up and absolute values and percentages for each dimension are obtained. In this study, the percentage of dimensions determined as goal areas was used, that is, dimensions where greater changes are expected.1616 Russell DJ, Rosenbaum PL, Avery LM, Lane M. Gross Motor Function Measure (GMFM-66 and GMFM-88) User’s Manual. Cambridge, UK: Cambridge University Press; 2002. 230 p.

Before starting the intervention program, the students were instructed in the theory and practice of FCC. Subsequently, an intervention program was developed in the home context with FCC, in which one visit was carried out per week, by groups of three to four students per family, with an average duration of 60 minutes each, for seven weeks, supervised by the two teachers responsible for the discipline. The number of visits, students per family, and the duration of the approach were defined based on the academic period, number of weekly classes, and number of students in the class, so that the strategies used during the intervention within FCC were fulfilled and that all students could experience the concepts of this approach in practice.

The intervention was carried out based on the family-professional collaboration model: (1) goals mutually agreed with the family; (2) shared planning; (3) shared implementation; and (4) shared evaluation.44 An M, Palisano RJ. Family-professional collaboration in pediatric rehabilitation: a practice model. Disabil Rehabil. 2014;36(5):434-40. DOI
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The strategies used are presented below (Box 1).

Box 1
Strategies used during the intervention in the home context within family-centered care

The results of this study are presented descriptively. The components described by the biopsychosocial model of the ICF were used to characterize each child. The assessment instruments were presented by the pre/post-intervention percentile or by the pre/post-intervention percentage score obtained. The graphs were created using GraphPad Prism/version 8.0. The families’ and students’ perceptions regarding the experience were extracted from the medical records and, after skimming, the content was analyzed, thus establishing the categories.

Results

Characterization of the study participants regarding clinical condition, disabilities (body structure/function), activity/limitation and participation/restriction, and contextual factors, are presented in Table 1. Table 2 presents the main descriptions of the FCC stages for each child, according to the weekly strategies used.

Table 1
Characteristics of the children according to the International Classification of Functioning, Disability and Health

Table 2
Description of the main points of the weekly strategies used in the FCC for each of the children and their families

The areas of the GMFM worked on with the children with neurological impairment were defined according to the main complaint of the parents and guided by the students. Child 1 had dimensions B (sitting) and D (standing) defined as goal areas in the FCC, while children 2 and 3 had dimensions A (lying down and rolling) and B (sitting) as goal areas. Children 4 and 5, both with delayed neuropsychomotor development, had goals agreed with their parents within the range of acquisition of each child in the different postures (child 4: prone, supine, sitting and standing; child 5: standing).

Children 1, 2, and 3 had an increase in their scores in the previously established goal areas, as shown in Figure 1, in which the pre/post-intervention GMFM-88 graphs are presented. When considering the target dimensions, a percentage change of 9.30% for child 1, 10.29% for child 2, and 6.24% for child 3 is observed. When applying the AIMS, a change was observed in the percentile of child 4, while child 5 remained at the same post-intervention percentile (Table 3).

Table 3
Alberta Infant Motor Scales (AIMS) Score

Figure 1
Evolutionary graph of the percentage scores of the goal areas of the Gross Motor Function Measure (GMFM-88) of the children (all with cerebral palsy) in the pre-intervention period and after 7 weeks of application of Family-Centered Care (post-intervention).

At the end of the intervention, families and students were asked about the experience (Table 4). Three main categories can be observed in the parents’ reports: (1) they perceived the child’s improvement; (2) they learned to know the child’s abilities better; and (3) recognized their value and contribution to the child’s intervention. Regarding the students' reports, the following categories stood out: (1) they observed the child's improvement; (2) the feeling of gratification of having seen the outcome of the interventions; (3) the rich learning experience; and (4) the barriers from a practical point of view, such as time spent commuting.

Table 4
Families’ and students’ report at the end of the home intervention with Family-Centered Care (FCC)

Discussion

The present study demonstrated that it is feasible to use FCC within an undergraduate course in physiotherapy, considering the clinical improvement of children and the positive perception of the families and participating students.

Children 1, 2, and 3 showed an increase of at least 6% in total GMFM scores, considering the goal areas. Although the results were presented in a descriptive way, it should be considered that differences above 5% in GMFM scores are considered clinically significant.1717 Russell DJ, Rosenbaum PL, Avery LM, Lane M. Medida da Função Motora Grossa usuário (GMFM-66 & GMFM-88): Manual do usuário. São Paulo: Memnon; 2015. 408 p.,1818 Bailey DB, Raspa M, Fox LC. What is the future of family outcomes and family-centered services? Topics Early Child Spec Educ. 2012;31(4):216-23. DOI
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Thus, in general, it is observed that the children with neurological impairment benefited from FCC. Regarding child 4, his inclusion in the study is the result of a recommendation for early intervention, due to the biological risk factors presented, and it was observed that he also benefited from FCC.

According to the interaction with the functionality/disability components, environmental factors can contribute as facilitators or barriers to the performance of the child's activities.66 Organização Mundial da Saúde. Classificação Internacional de Funcionalidade, Incapacidade e Saúde. Versão para Crianças e Jovens. São paulo: Edusp; 2011. 312 p. In this sense, important differences were observed in each of the families monitored, which may have contributed to the results found. Children 1, 2, and 4 had in common the fact of having participative and motivated parents and a home environment rich in stimuli. Even in cases where architectural barriers could restrict the child's participation, the parents would take them on daily or weekend outings. In this sense, it is known that family participation and cooperation in the treatment of children positively influence the results.1818 Bailey DB, Raspa M, Fox LC. What is the future of family outcomes and family-centered services? Topics Early Child Spec Educ. 2012;31(4):216-23. DOI
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,1919 Cossio AP, Pereira APS, Rodriguez RCC. Benefícios e nível de participação na intervenção precoce: perspectivas de mães de crianças com perturbação do espetro do autismo. Rev Bras Educ Espec. 2017;23(4):505-16. DOI
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Child 3 was initially characterized as a challenge to the implementation of FCC, considering some contextual factors such as the father's absence, the mother's lack of motivation, the child's irritability, and the scarcity of learning material and other resources in the home environment. That is, in addition to biological risk factors, the child lived in an unfavorable context, and was therefore also considered to be at psychosocial risk. Thus, associated biological and psychosocial risk factors make the child even more vulnerable to delays in development.2020 Ertem I, World Health Organization. Developmental difficulties in early childhood: prevention, early identification, assessment and intervention in low-and middle-income countries: a review; 2012 [cited 2021 Apr 12]. Available from: https://apps.who.int/iris/handle/10665/97942
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Nevertheless, during the sessions, the therapists conducted the treatment in order to eliminate hierarchies and make the mother more comfortable to expose her desires and ideas, in addition to encouraging the participation of the older sister during the sessions. Throughout the process, the family increased its participation and, with constant praise for the performance of activities, mother and sister began to feel more confident. Studies indicate that one of the positive results of FCC is the empowerment of the family in the children's rehabilitation process.2121 Novak I. Parent experience of implementing effective home programs. Phys Occup Ther Pediatr. 2011;31(2):198-213. DOI
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Some important barriers that impact the success of the intervention were observed in relation to child 5 and his family, which reflected in the absence of positive evolution, being the only child that did not present objective improvement on the applied standardized test. Considering the contextual factors, although the parents were receptive to the team in the home meetings, it was observed that they had difficulties establishing a time to play with the child during the week, according to the agreed goals. In this sense, according to the literature, families and therapists may have different beliefs/attitudes in relation to the intervention process. For some families, the care indicated by the therapist may come as a last priority, considering other social and family respon-sibilities,2222 Hammer CS. Toward a “thick description” of families: using ethnography to overcome the obstacles to providing family-centered early intervention services. Am J Speech Lang Pathol. 1998;7(1):5-22. DOI
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which may have been the case for this child.

According to Brown et al.,2323 Brown SM, Humphry R, Taylor E. A model of the nature of family-therapist relationships: implications for education. Am J Occup Ther. 1997;51(7):597-603. DOI
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23 there are seven different levels of family involvement, ranging from the choice of “non-involvement” to “total control of the entire process”. It is important to remember, therefore, one of the guiding principles of FCC: “the degree of involvement that families choose in relation to the treatment of the child must be respected.”2424 Rosenbaum P, King S, Law M, King G, Evans J. Family-centred service. Phys Occup Ther Pediatr. 1998;18(1):1-20. DOI
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Nevertheless, at the end of the seven weeks of follow-up, the parents of Child 5 reported realizing the importance of letting the child play on the floor longer and how much their participation in games made the child more motivated. Thus, it is worth noting that the change from a biomedical model perspective, in which the therapist controls the entire process, to a family-centered model, in which responsibilities are shared, is also a process that occurs gradually. It is possible that the family changes its position within the different levels of involvement over time and with the therapist's posture.2323 Brown SM, Humphry R, Taylor E. A model of the nature of family-therapist relationships: implications for education. Am J Occup Ther. 1997;51(7):597-603. DOI
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Regarding the perception of the families at the end of the intervention, in addition to the subjective report of the children's improvement, the parents claimed to have obtained greater knowledge regarding their children's abilities. In addition, they found that they could actually contribute to developing activities that favor the child's participation in their daily routine. These reports are in agreement with studies found in the literature.2121 Novak I. Parent experience of implementing effective home programs. Phys Occup Ther Pediatr. 2011;31(2):198-213. DOI
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,2525 Ziegler SA, Mitteregger E, Hadders-Algra M. Caregivers’ experiences with the new family-centred paediatric physiotherapy programme COPCA: A qualitative study. Child Care Health Dev. 2020;46(1):28-36. DOI
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In his study on the opinion of parents in regard to the implementation of home programs according to FCC, Novak2121 Novak I. Parent experience of implementing effective home programs. Phys Occup Ther Pediatr. 2011;31(2):198-213. DOI
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reported that, through the guidance and support they received from therapists, parents gained more confidence to help their children. Based on their experience with a family-centered program, COPing with and CARing for Infants with Special Needs, Zielgler and Hadders-Algra2626 Ziegler SA, Hadders-Algra M. Coaching approaches in early intervention and paediatric rehabilitation. Dev Med Child Neurol. 2020;62(5):569-74. DOI
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observed that parents naturally began to make the home environment enriching for the development of their children, as observed in the families of most of the children involved in the present study.

According to the students' reports, the experience was of importance to their training, helping them understand the real context, resources, and potential of families, which facilitated the choice of activities suitable for the needs of each patient. The students emphasized that learning within the context of FCC is very broad and that the experience will be valid not only during graduation, but will impact upon their approaches as future professionals within the family environment or even within the clinical environment. Johnson et al.2727 Johnson AM, Yoder J, Richardson-Nassif K. Using families as faculty in teaching medical students family-centered care: What are students learning? Teach Learn Med. 2006;18(3):222-5. DOI
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found similar reports when verifying what medical students were learning when working with FCC during home visits, finding that students learned valuable lessons from the experiences and that direct contact with families provided better learning.

Nevertheless, although FCC has several positive points and is widely supported by the literature, it is also necessary to discuss the difficulties that may be encountered2828 Litchfield R, MacDougall C. Professional issues for physiotherapists in family-centred and community-based settings. Aust J Physiother. 2002;48(2):105-12. DOI
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and mention the possible negative impacts of the inclusion of FCC on the undergraduate curriculum. Litchfield and MacDougall2828 Litchfield R, MacDougall C. Professional issues for physiotherapists in family-centred and community-based settings. Aust J Physiother. 2002;48(2):105-12. DOI
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reported the results of a qualitative study with physical therapists who worked within FCC through home-based programs and highlighted practical barriers, mainly citing the time spent commuting to the residence. Similarly, despite praising the FCC experience, a group of students in the present study also encountered difficulties during the process due to excessive time spent traveling to the child's home, in addition to facing unfavorable weather conditions. It is important to emphasize that FCC is a philosophy of care, therefore, it can also be implemented within the physical therapist's clinical practice in any therapeutic environment, not just in the child’s home. It is noteworthy, however, that one of its basic premises is that “the ideal behavior of the child occurs within a supportive family and community context” and one of its guiding principles is the involvement of all family members.33 Rosenbaum P, King S, Law M, King G, Evans J. Family-centred service: A conceptual framework and research review. Phys Occup Ther Pediatr. 1998;18(1):1-20. DOI
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Therefore, intervention in the home environment is not mandatory, but preferential because it optimizes the child's ideal behavior and the involvement of the whole family.

Furthermore, it is also worth highlighting certain other points presented in the literature that can be considered as barriers to the implementation of FCC in the practice of pediatric physical therapy. FCC cannot merely be added to previous models,2929 Bamm EL, Rosenbaum P. Family-centered theory: Origins, development, barriers, and supports to implementation in rehabilitation medicine. Arch Phys Med Rehabil. 2008;89(8): 1618-24. DOI
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as it would be necessary for the entire conceptual structure to be reorganized so that the change is effectively implemented to become centered on the family.2727 Johnson AM, Yoder J, Richardson-Nassif K. Using families as faculty in teaching medical students family-centered care: What are students learning? Teach Learn Med. 2006;18(3):222-5. DOI
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28 Litchfield R, MacDougall C. Professional issues for physiotherapists in family-centred and community-based settings. Aust J Physiother. 2002;48(2):105-12. DOI
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-2929 Bamm EL, Rosenbaum P. Family-centered theory: Origins, development, barriers, and supports to implementation in rehabilitation medicine. Arch Phys Med Rehabil. 2008;89(8): 1618-24. DOI
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Another point is that the the therapist may feel threatened by changes in their professional roles, where the family becomes ultimately responsible for the child's treatment.3030 Johnson BH. Family-centered care: Four decades of progress. Fam Syst Health. 2000;18(2):137-56. Full text link
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In addition, FCC requires skills such as communication, honesty, respect, tolerance, and flexibility from the therapist.3030 Johnson BH. Family-centered care: Four decades of progress. Fam Syst Health. 2000;18(2):137-56. Full text link
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Therefore, FCC is, in fact, a total change of conception and, for this reason, gaining experience in FCC while still an undergraduate is important, as it would enable the professional to have contact not only with the theoretical principles, but also with experiences that allow them to develop the necessary skills and competences.2828 Litchfield R, MacDougall C. Professional issues for physiotherapists in family-centred and community-based settings. Aust J Physiother. 2002;48(2):105-12. DOI
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,3131 Kuo DZ, Houtrow AJ, Arango P, Kuhlthau KA, Simmons JM, Neff JM. Family-centered care: Current applications and future directions in pediatric health care. Matern Child Health J. 2012;16(2):297-305. DOI
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Some important limitations in this study are the number of participants, the short period using the approach, and the sample being composed only of participants from a single Brazilian municipality. Thus, future studies that address a greater number of participants over a longer period of FCC are necessary, as are studies that evaluate different sociocultural contexts. Another limitation that should be addressed in further studies is the use of standardized assessment instruments that can measure the change in parental empowerment, as well as other aspects beyond the activity, within functionality according to the ICF model. It is suggested that in future studies instruments are used that verify, for example, the child's participation. The present study, however, contributes to the discussion on the inclusion of FCC on undergraduate curricula, in addition to demonstrating the potential for the development of future studies with an adequate methodological design to verify a cause-and-effect relationship.

Conclusion

In a relatively short period of time, most of the children in the present study reached the therapeutic goals and the families felt satisfied with the results achieved by their children. It was also observed that despite some barriers from a practical point of view, FCC has the potential to be included within a pediatric physiotherapy discipline. Considering the students' reports, the experience was of great importance for their professional training in pediatric practice. FCC proved to be promising and future studies are suggested with other methodological designs that enable the analysis of a cause-and-effect relationship, in addition to those that can confirm the feasibility of its inclusion on the undergraduate physiotherapy curriculum.

Acknowledgements

We would like to thank the children and their families and the physical therapists, who were academics at the time, for their participation in the FCC intervention.

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Edited by

Associate editor:

Aldo Fontes-Pereira

Publication Dates

  • Publication in this collection
    25 Mar 2022
  • Date of issue
    2022

History

  • Received
    06 July 2021
  • Reviewed
    08 Dec 2021
  • Accepted
    14 Jan 2022
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