Catherine Owens

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intensive therapy

Accessing Customized Technology Through Transdisciplinary

Intensive Pediatric Intervention to Promote Functional Life Skills

M A R A J O N E T, M A , C C C - S L P , is a speech language pathologist at CI Pediatric Therapy Centers in Madison, WI. She received her Master’s degree from the University of Massachusetts- Amherst. Her clinical interests include children with complex communication needs, including those who use augmentative and alternative communication (AAC), and pediatric feeding. She is passionate about using family and child centered care and working collaboratively with an interdisciplinary team. Mara has experience in multiple settings including inpatient and outpatient pediatric settings and schools. She is trained in the Get Permission Approach to Sensory Mealtime Challenges and Pragmatic Organization Dynamic Display (PODD). She has presented at national and international conferences on the topic of customized alternative augmentative communication.

CI Pediatric Therapy Center’s Advance program uses a transdisciplinary model of intensive therapy, which can facilitate positive outcomes in children and young adults with multiple neurological con- ditions through the acquisition of new functional skills using efficient and energy conserving move- ment patterns. When this model is paired with parent education and access to customized technolo- gy throughout the process, outcomes improve and home carryover is optimized.

TAY LO R D E VA L K , P T, D P T , is a physical therapist at CI Pediatric Therapy Centers and the Director of Development. Taylor received his Doctorate of Physical Therapy and Bachelor of Science from the University of Wisconsin-Madison. He is trained in the Intensive Model of Therapy and TheraSuit Method. He has given multiple national presentations at interdisciplinary conferences. Taylor specializes in working with children with neuromuscular disorders, pediatric orthopedic rehabilitation and working with siblings to enhance the overall therapy experience for each child and their family. Taylor’s prior work experiences include: working with the Birth to Three Model, school-based physical therapy and outpatient rehabilitation. Taylor is passionate about pediatric therapy because of his two sisters with neuromuscular disabilities who are his inspiration.

A N N A B E T H M A R T I N O , O T D , O T R / L , is an occupational therapist at CI Pediatric Therapy Centers and the Director of Programming. She earned a Master’s degree in Occupational Therapy from the University of Scranton, and her clinical doctorate in Occupational Therapy from Mount Mary University. Her clinical interests in providing collaborative therapy and assistive technology recommendations began while she was working at an approved private school for children with cerebral palsy where she worked to customize access for augmentative communication devices, environmental control units, and power wheelchairs. Annabeth has had training in customized wheelchair seating, neurodevelopment treatment, Every Move Counts, PODD, and sensory-behavioral approaches to therapy. She has presented at state, national, and international conferences about OT’s role in creating customized alternative augmentative communication systems, the importance of family-centered transdisciplinary therapy. 

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Children with complex medical profiles require a multitude of therapy services to meet their various needs, which can facilitate their ability to fully participate in their daily routines. Although the body of research focusing on the low-incidence population is growing, there continues to be debate about the type, fre- quency and approach to therapy, which is most beneficial. Re- search has demonstrated that an intensive model of therapy can yield more optimal outcomes compared to a traditional model of therapy for children and young adults with complex medical profiles, (Bailes et al., 2011; Mattern-Baxter, Bellamy, & Mansoor, 2009). Further, research regarding best therapeutic practice for children with multiple neurological conditions indicates that a combination of direct therapy intervention which addresses the acquisition of physical skills must be paired with providing clients and their families with access to resources and assistive technology to optimize outcomes, (Graybill, Self-Brown, Lai, Vinoski, McGill, & Crimmins, 2016). Therefore, incorporation of caregiver education and empowerment, as well as context-driv- en intervention (therapy which focuses on equipment trialing and training during sessions) can enhance the outcomes of both traditional and intensive therapy models for this population. Re- search has also indicated that transdisciplinary collaboration can support the needs of these individuals including those with complex communication needs, (Brady et al., 2016; Peabody et al., 2016). A transdisciplinary approach to an intensive model of therapy can facilitate positive client outcomes related to partic- ipation in functional life skills across environments, as a result of both an improvement of physical skills as well as access to resources and technology solutions for both the client and care- givers. The Advance Program, an intensive therapy program at CI Pediatric Therapy Centers located in the South Central Wisconsin area, is a unique and customized transdisciplinary approach to intensive therapy, which focuses not only on the physiological benefits of intensive physical and occupational therapy, but also capitalizes on utilizing this model to provide parent education and context-based access solutions by a multidisciplinary team.

INTENSIVE THERAPY The difference between traditional therapy and intensive

therapy is the frequency. In the research, intensive therapy is defined as a high frequency therapy program focused on im- proving functional skills yield by this increase in frequency as compared to traditional therapy services. Typically, in intensive therapy models, frequency varies between three-to-five times per week for 120-240-minute sessions for two-to-four weeks, compared to traditional therapy that is one-to-two times per week for 30 to 60-minute sessions. Intensive therapy programs that focus on physical therapy and occupational therapy are typically centered around motor learning. Motor learning, by definition is a sub-discipline of motor behavior that examines how people learn a motor skill. Motor learning can be reinforced through two different approaches: blocked practice and ran-

dom practice. Blocked practice refers to the practice of a sin- gle skill repeated over and over again. Random practice refers to a number of skills that are practiced in conjunction with one another within the context of natural daily activities, and is in- creased during home carryover without the therapist.

Intensive therapy works because of three key factors: super- compensation, recovery and muscle building. First, we overload the body by engaging in high levels of targeted activity (super- compensation), then we allow for approximately 20 hours of rest (recovery) and that cycle leads to muscle building over a period of time. We then use this muscle building for improved func- tional use in daily activities, including social participation and gross and fine motor development. Regardless of the method of intervention or types of activities a client engages in, increased repetitions lead to an increase in motor learning.

There are many different models of intensive therapy: phys- ical therapy and/or occupational therapy only, group offerings, constraint induced movement therapy, multidisciplinary teams, etc. Research supports the efficacy of specific intensive pro- grams and shows that children who participate in these pro- grams improve their functional skills. This varies between pro- grams that are exclusively physical and occupational therapy, group therapy, and a collaborative method. Intensive therapy often times is a more viable, more successful option compared to traditional therapy, especially for children with multiple neu- romuscular conditions.

TRANSDISCIPLINARY CARE A transdisciplinary approach to facilitating a customized in-

tensive model of therapy is beneficial in fully addressing the comprehensive needs of children with complex medical profiles. Transdisciplinary teams are defined by the high level of collab- oration throughout the evaluation and intervention process, in which practitioners with specialized knowledge and skills from various professions work across their respective scopes of prac- tice to meet the immense needs of the client (Peabody et al., 2016). Research across multiple therapeutic disciplines suggests that the transdisciplinary approach is beneficial for children and young adults with multiple disabilities, as the specialized skills of practice experts are required to yield optimal therapeutic outcomes for this population, (Peabody et al., 2016; Robillard, Bélanger, Keating, Mayer-Crittenden, & Minor-Corriveau, 2013). Further, the transdisciplinary model of patient care provides the highest level of satisfaction for both clients and their caregiv- ers in comparison to other models (Robillard et al., 2013). When practicing from a transdisciplinary framework, specialized ther- apeutic skills are developed in clinicians through practice with a specific population over time through the high level of informa- tion that is shared between team members. This team approach enables practitioners to provide more effective treatment by ad- dressing not only the physical needs but also the communica-

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tion and assistive technology needs that will allow the individual to participate in meaningful occupations.

CI PEDIATRIC THERAPY CENTERS: ADVANCE PROGRAM

At CI Pediatric Therapy Centers, our Advance Program uses a hybrid approach to intensive therapy in which we customize each program to meet the needs of the individual child, based on their strengths and the goals of the child and the family. We also use a transdisciplinary approach to provide the highest lev- el of customized and holistic family-centered care. Our program is collaborative, innovative and unique. We strive to make every program fun and functional. Each program is individualized to the child’s needs and abilities beginning with a consultation, and an initial assessment consisting of a multi-faceted approach to goal setting. A team of physical therapists, occupational ther- apists and speech-language pathologists develops and initiates the treatment plan in collaboration with the child, family and referring physician. This collaborative approach yields more suc- cess both during the program and after discharge. We base our program on the intensive model of therapy, but use numerous different treatment techniques, tools and devices to best meet our goals. We customize our program to meet the needs of in- dividuals with various abilities, and to assess their appropriate- ness for assistive technology that may optimize their functional participation.

CI’s Advance Program serves approximately 50 families per year, not only from within the South Central Wisconsin area, but from across the country. CI Pediatric Therapy Centers offers

housing for the clients and families participating in the program to ease the burden of commuting while participating in inten- sive therapy.

FREQUENCY AND DURATION Developed based-upon typical models of intensive therapy

in the literature, CI Pediatric Therapy Centers utilizes a frequen- cy of four-hours per day, five-days per week, for four weeks for the majority of the intensive clients. Through our own internal data collection, we have found that most clients in our program benefit from a full four weeks of intensive therapy. In fact, we fre- quently see more functional gains in the fourth week than in any of the previous weeks. Though this is the frequency we strive for, since we do not have exclusionary criteria related to age of the client, therapists determine the frequency for each client based on their individual needs and level of tolerance for therapy. Fac- tors taken into consideration when determining frequency in- clude age, daily routine and schedule (i.e., nap schedule, feeding schedule), and medical fragility.

TEAM MEMBER ROLES Although we use a transdisciplinary care model, each disci-

pline has a unique role within our Advance program. Each prac- titioner can provide their unique expertise in both the evalua- tion and intervention process to ensure a holistic approach to optimizing function and participation in everyday activities. This includes the expertise that each practitioner has related to de- veloping customized access solutions to promote age-appropri- ate functional participation across environments.

For clients with complex medical profiles and communica- tion needs, developing efficient and energy conserving meth- ods of accessing communication and their world is vital to their participation in desired occupations. Within an intensive pro- gram model, the importance of the team’s focus on building and reinforcing motor patterns which enhance the client’s ability to access program materials and activities is essential to establish- ing motivation for continued participation throughout the pro- gram. Throughout the program, the collaborative therapeutic efforts of the team must take into consideration and reinforce the integration of the child’s system of communication across environments, involving all of the client’s communication part- ners, and to support access to ongoing effective and efficient communication. The occupational and physical therapist can provide insight on optimal seating and positioning which pro- motes access to the client’s environment, efficient and energy conserving access methods for communication, access to pow- er mobility and functional participation in functional activities. Further, the promotion of functional ambulation skills and im- provement of efficient motor patterns targeted in an intensive program yields ease of access, increased communication oppor- tunities, and motivation to socialize with peers.

The physical therapist has clinical expertise in helping kids

Each client at CI receives a medal of achievement at the completion of the Advance intensive program, along with a party they help plan to celebrate their accomplishments while therapists review their home exercise program with caregivers.

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move and interact with their environment. This ranges from am- bulation (gait training), working with different assistive devices for mobility, assisting with gross motor development, balance, coordination and helping children meet gross motor mile- stones.  With the intensive model of therapy, a physical therapist has many different unique opportunities to work with the child to develop, enhance or refine skills. Ambulation for example can be addressed with partial body weight treadmill training, use of a gait trainer or another assistive device and also done with therapist assistance. This can all be worked on during an intensive therapy session or program with the goal of functional independent ambulation in mind. For kids who may need help with coordination, a physical therapist can provide blocked and random practice to help with motor learning of a difficult co- ordination skill that will help the child interact in play with his peers on the playground.

The occupational therapy practitioner has clinical expertise in enabling children to participate in desired functional activi- ties of daily living across environments. Through collaboration with clients, caregivers and team members, the occupational therapy practitioner works to match clients with customized en- vironmental designs, assistive technology and adaptive equip- ment to optimize their participation in meaningful occupations, while capitalizing and building upon their strengths and exist- ing functional movement patterns. In the intensive model of in- tervention, the occupational therapist strikes a balance between focus on engaging the client in motivating occupations that facilitate motor learning and strength building, and adapting activities and the environment to assist with functional partic- ipation. The occupational therapist determines the area of oc- cupation and specific activities that are most meaningful to the client and their family, and collaborates with the physical ther- apist to improve the underlying client factors that are impact- ing participation through intensive therapy. Activities of daily living including dressing, bathing, toileting and self-feeding are addressed by the occupational therapist throughout the inten- sive program to optimize function and problem solve the need for or adjustment of adaptive equipment. Expertise in activity analysis, activity grading positions the occupational therapist as a key provider of assistive technology, and leader on the trans- disciplinary team, whose roles include the coordination of team member’s expertise to provide appropriate assistive technology, along with client and family education.

Within this intensive therapy model, the speech-language pathologist has a unique role of pushing in and co-treating alongside an occupational therapist or physical therapist. Since therapeutic goals in a traditional intensive model of therapy are primarily focused within the scopes of practice of physical and occupational therapy, the role of the speech language pa- thologist (SLP) is centered around advocating for the commu- nication needs of the client. This encompasses the promotion and emphasis of the importance of communication as a priority

throughout all treatment activities. If a communication system is already established, the SLP not only models the language and navigation of the communication system, but also models all functions of communication (e.g., social participation, appro- priate protesting, requesting and advocating, etc.) and educates the family and other practitioners on the importance of aided language stimulation. If the client does not have an established communication system, the SLP will trial various aided and un- aided communication methods to facilitate functional commu- nication throughout the program. If the family has expressed interest in focusing treatment on developing a communication system that meets their child’s complex communication needs at any time throughout the Advance process, we can refer them to our specialty AAC program, AACcelerate (program described below).

TRANSDISCIPLINARY EVALUATION & GOAL SETTING At the point of the initial evaluation, the team works together

with the family to develop functional, family-centered goals in collaboration with all members of the team. Taking the time to establish common goals between practitioners and families can lead to improved functional outcomes, participation in func- tional life skills through improved physical skills and access to appropriate assistive technology and enhanced quality of life. The team works together to identify functional life skill goal ar- eas that can be addressed during intensive therapy including motor, self-care, feeding, alternative access, and communica- tion goals. Physical and occupational therapy practitioners have shared goals in this program, such that each can address every goal area within every treatment session. Practitioners work within their scope of practice to address client goals, with a ther- apeutic approach that is specific to their profession.

THERAPEUTIC APPROACHES AND TOOLS The Advance intensive program utilizes a variety of therapeu-

tic approaches and tools as part of its collaborative intervention. The team works to determine the appropriateness of each in- dividual to have these approaches incorporated into their pro- grams. These approaches include but are not limited to neu- romuscular re-education, therapeutic exercises and activities, partial weight bearing support gait training, gait training with various assistive devices and dynamic orthoses.  

ACCESSING CUSTOMIZED TECHNOLOGY Specifically, in the realm of accessing customized technology,

the PT, OT and SLP will all work closely together with each other and the family in order to recommend or trial various equipment and technology throughout the duration of the program. The purpose of each technology piece should be meaningful to the client, and facilitate participation in a meaningful occupation. We work closely with local durable medical equipment vendors throughout the program to ensure that clients are able to try a

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variety of adaptive equipment including gait trainers, adapted bikes, walkers and adapted bathroom equipment. A variety of self-care adaptive equipment and assistive technology utilized to access games, the computer and environmental controls are also available for use throughout the program.

FUN AND FUNCTIONAL When treating in an intensive model of therapy in which

clients are engaged in therapeutic activities for up to four hours each day, it’s important to go above and beyond to be creative and to elicit client motivation through fun and functional activities which target their goal areas. Addition- ally, engagement in functional activities that promote mo- tor learning can improve carryover at home. No two Advance intensive programs are the same, because every program is

developed based on the interests and priorities of the client in order to keep them engaged, motivated and improving.

Play and Leisure: Incorporating play into all treatment activities is the simplest

method of ensuring motivation and engagement throughout a session, while addressing the motor learning and strength-build- ing principles of the intensive model of therapy. Building and completing an obstacle course is a great way to work on strength, endurance, dynamic balance, transitional skills, eccen- tric muscle control and motor planning. Additionally, this activi- ty lends opportunities to engage socially while building a course with a peer, and to utilize executive functioning skills such as initiation of activity, problem solving and working memory. A scavenger hunt can address a variety of executive functioning skills, and also promote functional ambulation and endurance with a fun and functional goal in mind. It is not unusual to find stuffed animals hidden around the clinic at CI Pediatric Therapy Centers. If a child is motivated by rescuing stuffed animals, you can scatter them all around the clinic in strategic locations to fa- cilitate therapeutic activities such as ascending and descending stairs, navigating curb cuts outside, or hidden in a high place to work on overhead reaching. For older clients who may be motivated by sports, an intensive program can be transformed into sports camp. Clients arrive and go straight to their “locker room” where the therapist could sneak in some self-care goals, and then participate in any sport (basketball, tennis, soccer, etc.) that addresses their goals and facilitates repetition of functional movement patterns. The opportunities for leisure activities are endless. Therapists modify these play activities to isolate specif- ic muscle groups and target functional motor patterns that can improve not only the client’s ability to participate in that activity, but promote carryover of skills across various activities of daily living.

Access to customized technology is a huge component of play and leisure for clients with multiple neuromuscular conditions. Therefore, the team works throughout the program to determine the most efficient and energy conserving movement patterns a client can use to access play activities using alternative methods. This may include engaging in adaptive art projects with modi- fied paint brushes, playing board games using a switch adapted spinner or DJing a dance party with peers while trialing a variety of switches to access environmental control of the lights and mu- sic. Therapists can incorporate the use of adaptive equipment or the activation of assistive technology into an obstacle course to provide practice opportunities in a natural and playful environ- ment. The possibilities are endless, and therapists are guided in their creative treatment planning by the volition of the client.

Community Mobility While many intensive programs place a large emphasis on am-

bulation within the clinic’s gym, we love to take the opportunity

The main therapy gym space at CI Pediatric Therapy Center’s Fitchburg location including a variety of equipment utilized throughout the program across disciplines

Motivational canvases with CI’s core values hang throughout all of the clinic locations and reflect the mission of the collaborative intensive program.

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to work on dynamic movement skills throughout the communi- ty. Clients can practice ambulation, stair navigation, transitional movements and wheelchair propulsion both inside and outside of the clinic. We frequently go on community outings to the local park, drug store, grocery store, bakery, etc. Working on these skills in the community is often more meaningful for the client, not to mention motivating. In addition, community outings are a great way to incorporate communication and re-assess access meth- ods and seating and positioning needs while in various settings.

Activities of Daily Living Therapists collaboratively build functional skills that the cli-

ent needs to more efficiently and independently engage in daily activities. This is addressed through both the targeting of specific motor skills required to complete an activity, as well as by engaging in the activity during natural opportunities during the program. Self-care skills addressed in the Advance program include self-feeding, dressing, toileting and hygiene skills. The team typically approaches self-care activities with a careful bal- ance between facilitating neuromuscular reeducation to rein- force movement patterns required to more fully participate, and prescribing adaptive equipment or assistive technology to ease access. Clients may also engage in instrumental activities of daily living such as cooking and meal prep, or cleaning and chores as part of the program. By focusing on teaching the optimal ways of engaging in these functional activities during the program, clients and their families are better set up for home carry over.

Social Opportunities In a collaborative treatment environment in which multiple

therapists or peers are working and playing in the same space, many social opportunities are naturally available or can be easily

facilitated. Social opportunities are also typically motivating for most. Social opportunities are not only motivating to moving to the space of another individual to gain attention, but also to communicate and join in play with peers. Therefore, social com- munication opportunities are abundant. The therapist will often help facilitate a conversation depending on the needs of a child.

VIDEO HOME EXERCISE PROGRAM At the end of the program, our team customizes an individ-

ualized video home exercise program which includes videos of exercises and activities that can be done at home to continue progress and motor learning, tips for making modifications to the home environment to make it more accessible, and recom- mendations for assistive technology and adaptive equipment that has been trialed throughout the program. The home ex- ercise program also includes videos of the children completing functional tasks and activities in a way that they can also com- plete it at home. Many of these home programs also include rec- ommendations for follow up or consultation with outside pro- viders and community resources such as parent support groups, funding sources, and local vendors.

CAREGIVER EDUCATION AND CONTEXT-THERAPY Another component of CI’s Advance program is caregiver ed-

ucation. In addition to the video home exercise program that is sent home with clients and their families at the end of the pro- gram, caregivers are welcome to stay in sessions at the frequen- cy of their choosing and comfort. Our program model lends itself to allowing for more time to naturally incorporate parent education into therapy sessions. An intensive model of therapy in which families are in session with high frequency increases the natural opportunities to incorporate parent education and empowerment into treatment. The ease of this is magnified when using a transdisciplinary approach, as multiple providers are able to collaborate with the family to provide holistic educa- tion and resources, which span across the scopes of practice of each team member. Literature supports the fact that there is a positive correlation between education and empowerment of the caregiver and quality of life outcomes. A 2016 study indicat- ed that when parents are provided with resources about their child’s diagnosis, typical childhood development, and commu- nity resources specific to their child, they felt empowered to be more proactive in improving their child’s health, wellness and functional abilities, (Graybill et al., 2016).

The structure of our program enables the team to incorporate education on therapy methods, optimal positioning for func- tional participation in daily activities, use of assistive technology and adaptive equipment and community resources throughout the duration of the program. Educating parents about the pur- pose, use and availability of assistive technology and adaptive equipment empowers them to provide their children with ap- propriate technologies that optimize their functional partici-

An Advance client plays a switch adapted computer game with her physical and occupational therapist while working on dynamic standing balance in a partial weight-bearing support harness in the universal exercise unit.

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pation and quality of life. When this occurs within the therapy session, the approach is referred to as context-based interven- tion, (Slaman et al., 2015). Utilizing a context-based intervention approach within the intensive model can improve outcomes for clients with multiple neurological conditions, as this holistic ap- proach focuses on both improving client deficits and providing adaptations to the environmental context to solve functional problems. Additionally, research has shown that parents who are supported throughout the process tend to feel more em- powered to engage in prescribed carryover activities at home, which lead to improved outcomes for the child with a disability, as well as their parent’s perception of their contribution to the child’s quality of life, (Slaman et al., 2015). As the parent gains competencies and confidence throughout their involvement in the intervention process, they are better able to provide carry- over of therapy techniques at home, as well as obtain appropri- ate resources and equipment to improve their child’s quality of life. When therapists provide a balance of traditional and con- text-based intervention, families are empowered with tangible resources and client factors are addressed to improve functional participation.

AACCELERATE As previously mentioned, when families have an interest in

focusing specifically on developing a successful communication system for their child with complex communication needs they are referred to our specialized augmentative alternative com- munication program, AACcelerate. This transdisciplinary pro- gram is facilitated by a team of speech language pathologists and occupational therapists, who collaborate to develop a cus- tomized and robust communication system for clients without an established system or to boost the access and language skills of a client using their current system. Like Advance, this is a four- week program that runs at a higher frequency than tradition- al therapy services in order to target the variety of access and language needs of the client. At the time of consultation, the team determines if there is a need to acquire specialized equip- ment or devices to be trialed throughout the program. The team then works together to feature-match customized components of language design and access methods to set the child up for successful communication throughout the program’s duration. Additionally, this program provides families with education and resources throughout the process. Clients and their families leave the program with a home program that includes specific strategies for carrying over communication strategies at home, recommendations for ongoing traditional therapy and a plan for continuing development or pursuit of a robust, customized augmentative alternative communication system. Learn more at www.citherapies.com.

REFERENCES Bailes, A., Greve, K., Burch, C., Reder, R., Lin, L., & Huth, M.

(2011). The Effect of Suit Wear During an Intensive Therapy Pro- gram in Children with Cerebral Palsy Pediatric Physical Therapy, 23, 136-142.

Brady, N., Bruce, S., Goldman, A., Erickson, K., Mineo, B., Ogle- tree, B., Wilkinson, K. (2016). Communication services and sup- ports for individuals with severe disabilities: Guidance for as- sessment and intervention. American Journal on Intellectual and Developmental Disabilities, 121(2), 121-138,165-168. 

Darrah, J., Law, M., Pollock, N., Wilson, B., Russell, D., Walter, S., Rosenbau, P., & Galupp, B. (2011). Context therapy: a new inter- vention approach for children with cerebral palsy. Developmen- tal Medicine & Child Neurology, 53, 615-620.

Graybill, E., Self-Brown, S., Lai, B., Vinoski, E., McGill, T., & Crim- mins, D. (2016). Addressing disparities in parent education: Ex- amining the effects of learn the sign/act early parent education materials on parent outcomes. Early Childhood Education Jour- nal, 44, 31-38.

Mattern-Baxter K, Bellamy S and Mansoor, J., (2009). Effects of intensive locomotor treadmill training on young children with cerebral palsy. Pediatric Physical Therapy, 21, 308–319.

Peabody, M. & Demanchick, S. (2016). Interprofessional Op- portunities: Understanding Roles in Collaborative Practice. Inter- national Journal of Play Therapy, 25, 102-111.

Robillard, M., Bélanger, R., Keating, N., Mayer-Crittenden, C., & Minor-Corriveau, M. (2013). Interdisciplinary Models of Team- work in Augmentative and Alternative Communication. Inter- national Journal of Interdisciplinary Studies in Communication. 7. 35-44.

Slaman, J. van den Berg-Emons, H., van Meeteren, J., Twisk, J., van Markus, F., Stam, H., van der Slot, W., and Roebroeck, M. (2015). A lifestyle intervention improves fatigue, mental health, and social support among adolescents and young adults with cerebral palsy: focus on mediating effects. Clinical Rehabilitation, 29, 717-727.