By Nicole Klimas
Assistant editor of ADVANCE, February 25, 2002

MALVERN, PA—Four-year-old Justin is filled with boundless energy. He comes into the gym area, tumbling onto the mat in the center of the room, while his mom reminds him to take off his shoes. He runs around giving high fives and hugs to the adults standing around watching him and then dives onto the swing hanging from the celling.

Cassidy is more subdued. She clings to her mom as they enter the large room, and the 2- year-old shyly looks around with big blue eyes. At first she's a little intimidated by all the adults standing around, but she eventually gets comfortable as a friend coaxes her away from her mom and into the center of the playroom.

Looking around the room, visitors see walls adorned with brightly colored crayon cutouts; corners crammed with toys, including a dollhouse, a miniature kitchen set and cardboard building bricks; and a small trampoline near the mat that dominates the center of the room.

However, this is not your typical child's gymboree. Justin and Cassidy have come for a play date with their speech-language pathologists at Theraplay, a therapy center that provides pediatric physical, occupational and speech therapy services in a play environment. Justin was diagnosed with Pervasive Developmental Delay-not otherwise specified (PDD-NOS) right before his third birthday, and Cassidy has typical language delays. Justin and his mom, Joanne, come two hours a week for speech and occupational therapy, while Cassidy and her mom, Maryanne, visit once a week for speech therapy.

Clinicians at Theraplay use toys, games, puzzles and books to provide speech, physical and occupational therapeutic services to children ages 0-21. Most are between the ages of birth and 12. Many of the children have autism, auditory processing difficulties, articulation problems or expressive language delays. Clinicians also see children with cerebral palsy and Down syndrome.

Incorporating play activities into therapy sessions helps to foster carryover into activities outside of the therapy room.

A typical activity involves using miniature figurines of characters, like Winnie the Pooh or Scooby-Doo, to create scenes that address linguistic concepts, according to Laura Ackerman, MA, CCC-SLP. For example, a child may be asked to hide a figurine and then use language to direct a parent or clinician to find the object.

Activities also may revolve around concepts such as "same" and "different." For instance, a clinician may have a child sit on the floor and hand all of the objects that are the same to the parent or a stuffed animal. This activity works well for carryover because the parent can easily do this activity at home, such as matching socks while the parent is folding wash.

Bamyard Bingo™ is a favorite game of many of the younger children at Theraplay, reported Dana Boettinger, MA, CCC-SLP, who is on staff at a Theraplay center located in Horsham, PA. She uses the activity in exercises that address matching, naming and following directions.

For older children she recommends Hi-Ho! Cherry-O and Clue Jr., which require the use of expressive language skills to explain the directions, comment on the game, or describe what is going on. Boettinger also may use the games to do some articulation drills with the children. In addition, books, puzzles, and arts and crafts are used with all age levels.

Speech-language pathologists at Theraplay do some co-treatment with physical and occupational therapists depending on the individual needs of a child. If a clinician encounters a problem, there is a free exchange of information among the various disciplines. For instance, a physical therapist may offer recommendations regarding positioning for a child with cerebral palsy to ensure the best possible outcomes.

Family involvement and home activities are a major component of the Theraplay philosophy, which advocates the carryover of skills outside the traditional realm of therapy.

"It's wonderful if the children can use their speech skills here, but the world is much bigger than that," Ackerman said. "Mom and dad are with them more often, and they're their primary teachers. We like to give parents tools and skills to work with and teach the child so the child is continually learning."

Parents are involved at all levels of the therapy process. They can address questions and concerns with therapists and are invited to take part in the therapy session.

"They usually have an opportunity to see me set up a game," said Ackerman, "then I bring mom or dad into the game so all three of us are playing. I then pull myself out so I have an opportunity to watch, observe, and give the parent some pointers."

Parents are encouraged to bring familiar or favorite toys from home to be incorporated into their play therapy sessions.

"Laura gives me suggestions for things to do with Justin," Joanne told ADVANCE. "It's easy to tell a child with autism what to say, but Laura recommended that I ask lead-in questions that force him to think."

Therapy in a play environment is more functional than drill work, Ackerman said. Children learn skills in the environments in which they will be used.

"We try to make it as realistic as possible, but we give them the verbal cues and prompts they need to be successful communicators," Boettinger stated.

"For children with autism, environment is a big thing — it's the key to how well Justin is doing," said Joanne. "Children with autism won't progress as well if they are not comfortable."

"They learn a skill they can then practice on their own," Ackerman said. "They don't have an adult directing their play."

A major benefit of providing therapy in a play environment is that children tend to learn concepts more quickly and are less likely to get bored.

"They enjoy coming to therapy," she said. "Play is child's work; they get paid through verbal praise and tangible rewards."

By Susan L. Serbin
Times Correspondent

Lisa Mackell plays all day at work. That's what she says. Even though it looks like fun, Theraplay is serious business.

Mackell is a physical therapist who knew from the beginning of her training she was headed into pediatric work. In November 1991, she began a business as a provider of therapy services which was home-based, both in the sense of running it from her home and furnishing therapists for home care. Last October, Mackell opened a facility in Malvern, still offering home care, but expanding to a cheerful, primary-colored office for kids to spend an hour or so in all play-related therapy.

"I realized there were not enough places doing what we do," said Mackell, whose trusted office manager is her mom, Marcy Moyer, of Upper Darby, where the family was raised.

Speech, physical and occupational therapies may be offered at a number of fine facilities, but, Mackell indicated, the environments of rehabilitation centers or hospitals may be far less appealing to her population of kids from birth to 21 years of age. Theraplay has a staff which includes Mackell, six part-time therapists in the various specialties, and a pool of 150 other professionals who do home care across the region. In choosing the Malvern site, a former school just off Paoli Pike, Mackell said she wanted a location no more than half-hour drive from most of Delaware and Montgomery counties.

The children seen at Theraplay receiving PT, OT, ST or a combination of treatment, have a wide range of conditions among which may be developmental delays, neuromuscular disorders, orthopedic rehabilitation, genetic syndromes, sensory dysfunction and language disorders. While some children may need short-term therapy, to rehabilitate a broken bone, for example, others require long-range treatment. Mackell and staff appear adept at sorting through the maze of insurance coverage, even suggesting alternatives for using amounts of approved coverage.

Generally parents and children come to Theraplay as a result of conditions discovered from examinations. A physician's referral is needed, although physician, parent or insurance provider can contact Theraplay.

Chris Stellman, of Primos, has just started bringing daughter Sara for physical therapy. Stellman said Sara's needs were identified after seeing a pediatric neurologist last summer. While Mackell works with Sara, 4-1/2, mom sits by, offering encouragement. Even after only five visits, which Stellman said Sara seems to enjoy, there are improvements in daily activities like holding silverware and coloring.

Parent involvement varies, but Mackell said the staff is always happy to recommend and demonstrate ways children can be further helped at home, even if as seemingly simple as the way a baby is held during feeding.

Theraplay has just introduced two new therapeutic play groups, Move and Play and Talk and Play. The eight-week program of 45-minute classes costs $100. The programs have been developed for toddlers who do not fit into typical play groups available in the community, and meet various financial, social and physical needs for children and families.

"Families intrigue me," said Mackell, the mother of two children under 3. "You have to consider the medical condition, but the social condition as well, and use a common sense approach. I understand that a single mother might not have that 15 minutes some days to do exercises with a child, or the extra money for a toy that might be useful."

Watching Mackell work, one understands there is more to pediatric therapy than opening an office, buying equipment and scheduling appointments. Imagine trying to engage your child in an activity at a specific time in a specific way. Mackell and colleagues have a wealth of patience and many bags of tricks to go with their expertise.

"Kids won't work for anything, but they will play for everything," Mackell says.

Theraplay is located at Greentree Office Plaza, 40 Lloyd Ave., Malvern and can be contacted at (610) 722-0242.

By Jan Blair Battista
Special to the Local News

Few would argue that rehabilitation therapy is hard work. For adults, the motivation for completing challenging and repetitious exercises is the knowledge that such activities will make them well or at least improve their condition.

However, some professionals feel successful therapy in children requires a different approach that mixes effective rehab with a stimulating environment.

"Kids need therapy to be more like play than work," said Lisa Mackell, a licensed physical therapist with nine year's experience in pediatric therapy. "Children are a very special breed of people."

The belief that children's therapy should differ dramatically from traditional adult rehabilitation prompted Mackell to open Theraplay, Inc. last October after successfully operating a home care therapy business since November 1991.

"Theraplay is based on the foundation that play experiences are the ideal forums in which children learn and develop," Mackell said.

The Malvern-based center is the only private Chester County facility that offers individual therapy to children from birth to 21 years old, and is staffed by seven part-time licensed therapists backed by a pool of more than 140 independent physical therapists.

Theraplay treats a wide variety of conditions from cerebral palsy to developmental delays, language disorders and orthopedic problems. Common disorders like stuttering and coordination difficulties are dealt with regularly.

Most rehab sessions occur in a large gym area that offers a comfortable, relaxed environment closely resembling a day care center. Giant balls, small benches, mats and other non technical equipment lack the intimidation factor that scars children ant other facilities, making Theraplay a pleasant experience for even a small child.

"I love the family aspect of it," Mackell said. "We take into account the family dynamics and try to include the whole family in treating the child.

"Bright colors, fun toys and cartoon decorations add to our casual atmosphere. We give out stickers, we paint and we play with the kids, which keeps them coming back for therapy." Mackell said.

Combining Work and Play to Help Children Communicate
by Darlene Alu

"Some cases are more difficult than others, so we're always trying new things in an attempt to keep the children interested but also meet their goals," explains Rolfe, who has been a speech therapist at Theraplay for almost a year. The majority of her patients are children with autism, Down's syndrome, Central Auditory Processing Disorder (CAPD) and apraxia. She also sees patients with fluency or general articulation disorders.

"The majority of my cases deal with autism," says Rolfe. Although her autistic patients range in age from two to eight, she says that many of them are preverbal. "Because they haven't started talking yet, we work on the prerequisites for language." Such prerequisite skills include paying attention, taking turns, making transitions, and maintaining eye contact. According to Rolfe, autistic children vary so greatly in their abilities, depending on the severity of their disorder, that treatment is never the same for any two of these patients. "There are so many different levels at which they can be. We might work on increasing their length of utterances, answering questions, formulating questions, telling about remote events, or grammatical training."

Rolfe's caseload also includes a significant number of children with Down's syndrome. For these patients, Rolfe says that finding ways to decrease the frustration they often experience in their attempts to communicate is a top priority. "Because Down's syndrome patients have a tendency towards low-toned facial structures, we work on oral motor activities and exercises that will strengthen their lips and tongues so that their clarity of speech will improve," she says. "A lot of articulation problems as well as language problems are associated with this disorder, so we also work on any specific sound errors the patients may have, as well as increasing their vocabulary and learning to use gestures to communicate."

Rolfe's patients in therapy for fluency problems are all of preschool age, so she incorporates a lot of fun activities into their sessions. "Showing them smooth, slow models of speech through books with characters like Snooky the Snail introduces them to different concepts that carry over into aspects of speech, like taking your time."

Another fun activity Rolfe uses is a treasure-hunt game for her patients with auditory processing disorders. "We work a lot with following directions, so the treasure hunt stimulates them to follow different commands we give them, which lead to an ultimate goal or prize," she says. "We just try to incorporate play into their therapy as much as possible," continues Rolfe. "For instance, in general articulation training, we may have them make up a story with certain sounds in it or play 'I Spy,' finding things in the room that begin with a particular sound."

As one of the newer therapists at Theraplay, Rolfe mainly evaluates children when they first report to the facility, then recommends and provides treatment. Treatment sessions usually last one hour, which includes a wrap-up session during which Rolfe instructs her patient's parent(s) regarding at-home activities for their child. "We always tell them what goals we're working on, how we are working on those goals, and how they can try to continue it [the treatment] at home," she says. "The treatment simply is not beneficial for the child if it's not carried over in the home. Goals can be met much more quickly if the children are working on them at home in addition to their treatment here, and carrying over their goals in the home helps them to carry them over in the real world."

Theraplay often employs "cotreats," in which the speech therapist and another therapist will work together in a session with a child. For instance, an occupational or physical therapist may collaborate with a speech therapist. "Cotreats not only maximize the child's therapy, [they] also enable the two therapists to learn techniques from each other's discipline. Sometimes what the OT does with a patient will motivate him to accomplish more of his speech tasks. I notice it especially with our autistic children. They have sensory needs that, when approached by the OT through movement activities, for example, [help make them] calmer, and their speech flows easier.

"Also during cotreats," Rolfe continues, "there are little things you can learn from the occupational therapist or the physical therapist that will benefit future treatment with a child. I also gain a better understanding of that child's disability when I see certain strategies from other disciplines working in therapy."

Rolfe enjoys Theraplay's small, close-knit atmosphere because it promotes helpful communication between disciplines. "It's a great environment for any therapist, but especially for new therapists because all of the disciplines are right in the same facility. That allows us to bounce questions around or give support to each other, and we all learn so much from one another," she enthuses. "Having other speech therapists here as -- well as multiple people from other disciplines every day -- I feel as though I've learned more in the time I've been at Theraplay than I learned in the year I spent at my previous job." Several home care therapists also work out of Theraplay, and they often provide support as well. "The home care therapists are more experienced and are very helpful when we call them with questions," says Rolfe. "They usually get back to us within 24 hours and always have time to talk to us as they travel between appointments."

Rolfe chose speech-language pathology as her vocation because she "wanted to have a career that focused on helping people." Since she knew that communication is such a vital part of everyday life, she decided to concentrate on helping people habilitate and rehabilitate in that area.

In addition to continuing to study speech disorders, Rolfe is interested in learning more about swallowing and feeding disorders in infants and preschool children. "We have some children in our caseload with dysphagia. The more patients I see, the more I have found that there are many children below the age of three who have speech and language problems as well as feeding problems. That is very interesting to me. [Dysphagia] is different than any of the disorders I've really treated so far," she continues. "Trying to determine why some children prefer certain foods or textures and reject others, and how it relates to their speech and language development really interests me, and I'd like to know more about it."

Continuing education courses specific to dysphagia and numerous other topics are available to speech therapists: Rolfe says she takes advantage of these whenever she can. "There are in-depth training seminars out that enable us to learn more about different disorders," she says. "Having gone to some of the seminars that deal with feeding disorders and working with a therapist who is here from Children's Hospital of Philadelphia, I've learned a great deal in the area of feeding, but would still like to learn more." Rolfe credits her experience at Theraplay with expanding her knowledge of sensory integration which has, in turn, helped her better understand and more effectively treat her feeding patients.

Another of Rolfe's ambitions is to attain further training in behavior therapy and therapy techniques with autistic patients. "Because of the nature of autism, behavior issues exist in treating those patients. All autistic children are different, so a lot of techniques are trial-and-error in overcoming their decreased attention. I just feel that if I have more knowledge in that area, it would help me to find ways to go about getting past that block and beginning treatment, which would make the therapy more efficient. What works in one situation doesn't necessarily work in another, so I take time to read up on autism a lot in journals to see what others in the field are trying."

Rolfe has not narrowed her scope of interests to the study of autism alone, however. "We're seeing an increase in the amount of Down's syndrome patients at the clinic," she says, "so I also look for courses that deal with speech and language problems with Down's syndrome children and speech therapy techniques for these children." Although speech therapists are required to take continuing education courses in order to maintain their certification, Rolfe feels that continuing education would be necessary even if it were not mandatory. "I couldn't imagine not taking them [continuing education courses] because it is such a diverse field with so many disorders and there are always new diagnoses and treatment techniques coming about. I just think that these courses allow me to keep up on everything in the field."

Although Rolfe thoroughly enjoys her time working with children, she naturally experiences the occasional frustrating case. There have been times, she explains, that a patient simply doesn't respond to the therapy being administered. "You'll find you're doing all the different therapies you can, you're trying different techniques, other therapists are doing the same things you are in trying to get the goals met, but for some reason or another, progress isn't being made. You want to see your patient getting better, [but] sometimes he doesn't, so you have to decide whether to keep him on a little bit longer or to discharge him.

"It's challenging as a therapist, because you just don't want to let anyone go who has a communication problem," she continues. "However, it's really not appropriate to continue therapy that isn't making any progress. You wonder if it's really beneficial for that child to go on getting therapy -- or are you just causing him more frustration?

"I got into this field to try and help kids communicate better," Rolfe states. "I really like working with the kids and seeing them make progress and eventually meet their goals. It's so rewarding to discharge a child because he's met all of his goals and is functioning age-appropriately. I have a great feeling to know that I helped them through all of that, and they have a great feeling when they get to graduate from speech class!"

Although Rolfe is committed to increasing her knowledge in several areas of her field, she has no aspirations at this time to pursue a position in management. "I feel that as a manager or administrator, you lose time with the patients," she says, "and I so enjoy my time with the children." Rolfe is confident that she will not change her mind about this. "Even when I am older and have more experience, "I truly feel that I will prefer to be a staff speech therapist. The best thing about a job as a speech therapist is getting to work with the kids and that is what I want to continue doing. The more time I have with the patients, the happier I am."

Melinda Rolfe, MS-CCC/SLP is a speech therapist at Theraplay, Inc. in West Chester, PA. She earned her Bachelor's of Science degree from East Carolina University and her master's degree from East Stroudsburg University. She holds a Certificate of Clinical Competence from the American Speech-Language and Hearing Association (ASHA).

Helping Children and Their Families Overcome Challenges
by Angela Havrilla

A startling childhood experience led Patricia Delaney, OT, to her current career as a therapist and the future education coordinator at TheraPlay Incorporated in West Chester, PA. When she was 13, her grandfather was flung 20 feet from a tree he was cutting with a chainsaw, shattering his pelvis in four places and dislocating his elbow. "The trauma he went through was so vivid to me," she recalls. "Here was this six-foot-two-inch man who was very strong and stoic, and to this day, I have never ever seen him cry like that."

After the accident, Delaney's grandfather was in the hospital during his rehabilitation. He was started on a tilt table, but initially fainted or vomited whenever he was placed in an upright position. For two harrowing months, he made little progress. According to Delaney, her grandfather "really was losing heart for what was ahead d of him, and what kind of life this was going to mean for him."

Then one day, an occupational therapist began to work with him.

"I'll never forget her because she was my size, and I was 13. She was tiny and he just towered over her. He said, 'I can't even sit up,' and this OT just replied, 'What do you want to do?' and she really got into what was meaningful for him. The OT made small, meaningful goals and told him how the therapy was going to get him to where he wanted to go -- not just because it was an insurance goal or in order to discharge him," Delaney says. Her grandfather's OT took the time to learn about his hobbies, one of which was photographing lighthouses, to motivate him. "The OT said, 'This is how we can get you into a chair so you can ride in a car to get to your lighthouse.' and he started getting this whole inner drive to be more than what he thought he was going to be."

Eighteen years later, Delaney says her grandfather does many things for himself -- including yard work. "I think a lot of his inspiration came when the OT just broke things down into something very basic, very simple, and very real for somebody who just saw the world as so challenging, and saw what was ahead of him as being so unreachable."

From that point on, Delaney wanted to become an occupational therapist and began volunteering in hospitals and working in physical therapists' offices during summers throughout high school and undergraduate school.

She graduated from Arcadia University (then Beaver College) in Glenside, PA, in 1994 with a Bachelor of Science degree in biology and a minor in psychology. When she pursued her Master's of Science degree in occupational therapy at College Misericordia in Dallas, PA, Delaney was living in Connecticut because her husband was in the military. She drove five-and-a-half hours and approximately 450 miles to Misericordia every other week for a weekend master's program -- and continued to do so for three years while also working full time in the OT field. When Delaney and her husband moved back to their home state of Pennsylvania, she finished her master's degree studies by completing her affiliations.

"My last affiliation guided me toward TheraPlay Inc., where I work now," she says. "The woman I was working for at the time suggested giving them a call because there was not enough work at her practice. I sat in her office and set up an appointment with TheraPlay, after my mentor called and said to the owner, Lisa Mackell, 'Hey, I have this student who wants a job.' Then she just handed the phone to me, and Lisa said, 'I hear you want a job: let's set up a date.' We set up a date and that's kind of how it started," Delaney recalls.

That seemingly casual beginning launched her career at TheraPlay as the facility's first full-time OT in February 1999. Prior to that, two OTs put in several hours per week. "In the beginning, Lisa Mackell said, 'I have cases I can give you, although it's not going to be all here [at the office] but as long as you're willing to put in what you need, we'll make it work and build an occupational therapy department that works five days, 40 hours a week.'" Delaney explains.

TheraPlay, Inc., serving children from birth to 21 years of age, has an office in Horsham, PA, and a main office in West Chester, PA. TheraPlay treats a broad spectrum of pediatric disorders and injuries by incorporating play into therapy sessions.

"I think the first two weeks I was there I must have done 19 evaluations a week," Delaney continues. "It was amazing. I worked in Philadelphia in very [economically] challenged areas, with a lot of really wonderful families. I'd drive back to the office from Philly, then treat children at the Malvern office [the former location of the West Chester office]. I started out with a couple of kids on my caseload, and then it just kind of grew to the point where I couldn't get back out to Philly because the demand was getting very high at the [Malvern] office. It blossomed from there and now we're up to about five to six full-time OTs in our offices, and that was something we didn't foresee."

Delaney is impressed by TheraPlay's team approach, in which therapists across different disciplines collaborate to treat children. Although children come to TheraPlay for numerous reasons, many of the children Delaney and her colleagues see suffer from autism or autism spectrum disorders. "I would say at least 40 to 60 percent in our West Chester office and 60 to almost 70 percent in our Horsham office have a diagnosis somewhere in the autism spectrum disorder (ASD) range," she says. "We're working with children with poor central integration, and so we provide the sensory integrative therapy component to enhance their learning. We help them to better integrate information from their environment so we can help move them into the more abstract thinking, problem solving, and motor planning components of learning. The biggest piece that is affected in children with poor integration is their engagement with others. Although this deficit typically is associated with this diagnosis pattern, we can help kids move beyond it. Our social development skills groups offer some of that experience, although we may be doing one-on-one [at] first before they're even ready for group experience."

Although a diagnosis of autism or autism spectrum disorder is devastating for parents, Delaney dwells on what the children can do, rather than their deficits. "We don't enjoy labeling children:I'm not in that business. I'm in the business of moving them toward a greater function. I'm in the business of having the families learn to love their child for who they are, and develop them to their potential, whatever that may be."

Delaney, who is currently TheraPlay's West Chester center manager, will be assuming a new position educational coordinator. "I've sort of spearheaded going out into communities and doing a lot of consultations," she explains, "and have gotten really involved -- whether it be in schools, daycares, or even [with] behavioral health support professionals." Delaney began conducting in-service lectures as a natural result of parents asking her to speak to their children's teachers. "A certain parent will pay for me to go to their child's school and the teacher will say, 'I think everyone would like to know this.' So the next teacher in-service day, they ask me to come and speak to other teachers. Now I go to a couple different things annually that they ask me to do. I'll come in and give them a background on what they want to know, whether it be for two hours, three hours or 45 minutes," she says.

In her new role, Delaney will send various staff members of TheraPlay, including herself, into the community to educate teachers, doctors, daycare workers and any other interested individuals.

"Education is something the community is grappling for. They're looking for someone to help give them real functional pointers," she notes. "They say things like, 'As a teacher, what can I say to a parent when I've tried X, Y and Z?' or, 'So you're telling me this certain thing: what do I do with that?'"

Delaney is confident that she and her colleagues will be able to give professionals and family members the off-site help they need. "We have a ton of resources within our four walls at TheraPlay. We have PTs and OTs and speech therapists. We also have teachers on staff, and I say to teachers, for example, 'Have them [families] come in if they are concerned, and let's find out what's going on.' Or we'll give the parent a phone call and we'll talk with them and see what's going on that way. It's really great that there are people out there who want to learn so much." Delaney says she loves educating, and if her alma mater were not so far, she would enjoy being an adjunct professor there. "Being an adjunct professor may not be the thing that's going to happen anytime soon," she adds, "but I know I can do education in the community in which I live, so that's my emphasis right now before I get to those other kinds of levels."

She plans to devote certain times during the week to specific tasks that will come along with her new role as educational coordinator, but will also continue seeing patients. "My hope is that I never leave the patient environment. I think my skills and my true love are there, and I don't want to become someone just behind a desk that orchestrates things.

"I get very vested in the kids that I work with," she continues, "even though with the team approach at TheraPlay, we may not always see the same child each time. I'll inevitably have two or three parents a week that will come to an emotional _expression of some kind and want to share that with us. I love being part of them saying, 'Oh my God, I can't believe he is now enjoying this or that; I wish we would have found you guys earlier.' Or maybe, 'He's told me how much he enjoys being here and I'm seeing progress in school, where the teachers are writing notes back, saying, "Who is this kid?"' Those are the things I love hearing. You don't get those comments every day, but you get them quite often and when they do come, you just have to be in that moment and be there for that parent, because this is their whole life."

She also says her experiences with these families enhance her relationship with her own 15-month-old son. Delaney, who is also about four months pregnant, empathizes more deeply with the parents she sees now that she is one, too.

"This is a part of them that's been challenged," she says of parents who must watch their children struggle with a disability or problem. "This is part of them that they see in pain, and this is part of them pining away to be something more than what they are. Then, when the children finally feel they are moving forward and they start having a better attitude about themselves, the parents have a better attitude about themselves. The parents feel more weightless, and not as heavy -- and that's my job. That's what I love doing."

Patricia Delaney, an Occupational Therapist at TheraPlay Inc., graduated from College Misericordia in 1999 with a master's degree in occupational therapy. She graduated from Arcadia College in 1994 with her Bachelor of Science in biology with a minor in psychology. She holds certifications, in Sensory Integration and Praxis Testing (SIPT).

Patients Play Their Way Through Treatment
by Angela Havrilla

"Kids don't want to work," explains owner and physical therapist Lisa Mackell, "and they say, 'You're not going to make me do any work today are you?' We'll say, 'No, we're not going to do any work.' Pretty soon, Mackell relates, they'll ask to play with play-dough, not even realizing that it's part of their treatment. Before long, "We've got them playing with play-dough and pulling it apart and working on their hand/eye skills and coordination by jumping to get it," she laughs.

With approximately 50 employees including therapists and administrative staff, Theraplay sees patients from birth to 21 years of age. Youngsters and their parents come to Mackell's facilities seeking treatment for a broad range of problems: conditions related to prematurity or developmental delays, stuttering or serious and debilitating neuromuscular diseases. Some come to Theraplay for remediation of extremely poor handwriting, disorganized behavior in school or difficulties playing sports. Others come to rehabilitate after devastating injuries. Theraplay also treats children with autism, Down syndrome and cerebral palsy.

Mackell founded Theraplay in 1991 as a homecare organization. She opened it as an outpatient center in 1996 in Malvern, PA. Theraplay then opened a second office in Horsham in 2000 and moved its first office from Malvern to West Chester in May of 2002. The West Chester center is Theraplay's corporate headquarters, although staff therapists often travel between the two facilities - and even to some of their patients' homes. Theraplay also has contracts with local schools and offers six-week playgroups to patients.

Mackell, who graduated in 1988 with a Master of Science in Physical Therapy from Philadelphia College of Pharmacy and Science (now University of the Sciences, Philadelphia), says that even as a student, she knew she wanted to provide unique services for young patients. "I knew there were no other providers out there really treating children the way I believe they need to be treated -- not only as individual patients, but as members of families," she explains. "If it is an injury, we work to maximize that child's rehabilitation. If it is a child with a disability, we see how to make that child a valuable and accepted part of the family while getting therapy and working on their goal."

In keeping with Mackell's mission to treat the whole family, Theraplay facilities are open six days a week, with extended hours Monday through Thursday. "This [operating schedule] gives the opportunity for not only Mom to come, but for Dad to come, too, and learn some of the activities, " she explains.

"A child could come to my office three times a week," Mackell continues, "but if the family doesn't carry it over at home, what we do has very little, if any impact. They've [parents] got them for 24 hours a day all the other days. Hopefully, what we're going to do is use our sessions to start the goals, start the tasks and learn what we need to teach the families so that they can carry it over."

She offers specific examples of how family involvement enhances treatment. "If it's the infant with torticollis [a deformity in which the head tilts towards one shoulder and the chin points to the other], we're telling them, 'Don't let them lean to this side in the car seat. Roll up this towel to put on this side of the head so that they're not only looking to the right.' Maybe we're saying to the parent, 'You know what, Mom? His arms are really weak, or his trunk is really weak, [so] let him carry the laundry basket downstairs.' These are little things that may become chores for [the patient], but sometimes, the parents just feel sorry for their kids and they compensate [for the child's disability] so much that they're working against themselves."

Theraplay PT Heidi Woolard illustrates Mackell's point more by giving another example. "In PT, when we work with babies as little as a week old, all of those parents come and are active during the session because I am also educating the parent on how to do the exercises and stretches the proper way. I may only see this child one, two, or three days a week, but they need [to do] the therapy everyday," she says. Woolard says that one of the greatest challenges of her job is trying not to become too attached to the children she treats. Woolard, who has worked at Theraplay for two years, has a particular interest in children with Erb's palsy. Still, she has no plans to limit herself professionally: "I will continue to research and learn more about all pediatric diagnoses," states Woolard.

Mackell shares her employee's enthusiasm for continuing education. Theraplay pay for continuing education seminars or conferences that enable employees to increase their knowledge and hone their therapy skills. This year, Mackell plans to bring various guest speakers to Theraplay for two all-day workshops.

She considers such an investment in her staff's education worthwhile because she holds them in high regard. "We're very fortunate with our staff. You don't go into pediatrics unless you know you want to do it, because it can be extremely time-consuming, extremely exhausting, and you need to be willing to play all day long," she says. "It sounds like the dream job, but you have to really be ready to be up for that all day long. There is no 'I need a break. I've got a headache.'"

Since Theraplay participates in most of the local university and college affiliation programs, Mackell has her pick of talented therapy interns to hire. "We have everybody from one or two years of experience to people with 10, 15, 20 years of experience in the field who come to work with us," she says. She adds that they are attracted to Theraplay's philosophy of pediatric therapy in a play environment and the practice's family-centered treatment model.

Another special feature of Theraplay's treatment is that patients get a chance to form relationships with more than one therapist. Each time a child comes to Theraplay, he or she may have a different therapist than they saw during the previous appointment. Mackell says she and her staff have found that this approach promotes "faster progress with goals and better carry-over.

"Let's say you have a child who is very shy or who has a hard time learning from people or dealing with people," she explains. "If he or she always comes to see me, I've increased [that child's] contacts by one, and what good have I really done?" In addition to helping children develop their social skills, having more than one therapist on each case also means a more innovative treatment plan for each patient. Mackell says each therapist has a unique perspective that enriches the program, and each session is documented so the next therapist will know what the previous one accomplished with the patient.

Theraplay's Clinical Coordinator, Maureen Hugel, a PT with 19 years of experience, agrees with Mackell that this approach works well. "It is a dynamic learning environment with highly skilled therapists who have a wide variety of backgrounds coming together to meet the therapeutic needs of children and their families," she says. "I am always learning from the staff and the children and their families despite my number of years as PT and administrator. We are the only entity of its kind in the area that provides comprehensive services to families with children with therapeutic needs."

Theraplay also goes the distance to help families with their health insurance concerns. "We've had parents who have come here and said there was no way their insurance company was going to pay for the child's therapy because they had tried to get it covered before," Mackell says. "I'll tell them to give me their information -- I'll call the insurance company and work with them on why the child needs therapy in order to get the therapy covered." Mackell stresses that in order to win and maintain coverage, careful documentation of both treatment and measurable progress is crucial. For families who are uninsured or underinsured, Mackell and her staff stay updated on available state and county programs so they can direct families in need to them. In fact, Mackell and her billing staff strive to get daily updates on the latest developments with various insurance companies in regard to what is and is not being covered. This practice helps Theraplay staff educate families on what options their particular insurance coverage offers.

In pediatrics, the ratio must always be one therapist to one child. This is a cost-intensive requirement, because most insurance companies do not differentiate between pediatric and adult therapy-in which patients may be treated in a group setting. This can create obstacles to families getting coverage for treatment at Theraplay."

Mackell and some of her staff make time to meet with local doctors' groups in order to keep lines of communication open regarding healthcare and insurance issues and to keep physicians informed about new developments at Theraplay. Theraplay is active in the community as well. "We try to do a lot of community fairs, community walks, continuing education conferences, staff luncheons, and family information seminars," Mackell says.

She plans to keep Theraplay vibrant and growing, with plans to open a new center in nearby Delaware County, and perhaps another in the state of Delaware after that. She is also excited about the West Chester facility's recent acquisition of an Interactive Metronome® (IM). This instrument enables children to work on language and attention skills. Mackell and her staff also believe in supporting hospital-based clinical research. Although they are not involved in research themselves, Theraplay helps promote local hospitals' research by referring certain patients to their studies.

Mackell knows, however, that the true test of Theraplay's success lies in the willingness of young patients and their families to follow their treatment plans. As surely as the proverbial spoonful of sugar helps the medicine go down, a sprinkling of play helps the PT exercises get done. Mackell gets direct feedback from the comments of children, siblings and parents. One comment made during the summertime by the sister of a patient who had managed to break his arm two years in a row stands out in her memory. "The sister said, 'Next summer, I'm breaking my arm so I can come [to Theraplay]!'" she recalls. "Well, we must be doing something right."

Theraplay Inc. provides physical, speech, and occupational therapy for patients 21 years of age and under. Centers are located in West Chester, PA, and Horsham, PA.

Angela Havrilla is a freelance writer from Pottstown, PA. She is on the editorial staff of NEWS-Line for Physical Therapists.