Fidelity Tool: Interventions to Improve Function in CP
This fidelity tool has been developed to support clinicians and organisations to reflect on their current practice, and how this aligns with the International Clinical Practice Guidelines for improving function in cerebral palsy. These guidelines were developed for children aged 2 to 18 years who have a functional, child-centred goal. The Fidelity Tool Guidance Document and Fidelity Tool word documents can be downloaded here:

Fidelity tool              Fidelity tool guidance document
How to use this tool:
• It is freely available, no registration is required. There is no limit on the number of times you can access the tool.
• For more information about one of the 21 question answer options for each, hovering over the option will give you a more detailed description for each (hover not available on a mobile device). For example, hovering your cursor over the words 'No demonstration/0' for any of the 21 questions will give you a more detailed description of what not demonstrating that aspect of clinical practice means in practice. You must hover your cursor directly over the words, as hovering over the box itself will not lead to the description coming up. 
• Not all items will be applicable to the therapy session being observed, therefore items that are not relevant to that session can be rated N/A, and will not contribute to overall score.
• You submit the form by clicking the black arrow at the bottom of the page.
• Answers are able to be changed at any time. 
• You can remain anonymous, or you may fill in your/others names to assist when looking back at past session responses.
• You can leave the tab open and your scores won’t go away, however if the tab is closed then the page will likely refresh and responses will be lost.
• Upon completing the online tool you will receive an email with all your responses and your score as a percentage. After clicking on the URL to view results, there is an option to download your results as a pdf.
GOALS
1. Client chosen

Time should be spent understanding what is important to the child, and setting functional goals that focus on improving the child’s ability to participate in activities that are most important to them. Goal setting may be done through an interview or using goal-setting tools if available (eg. Canadian Occupational Performance Measure).
If the child is unable to identify or articulate their own goals, families should be encouraged to set goals considering the child’s preferences and interests.
2. Goals are well defined and measureable

Goals should be clearly defined and detailed enough to ensure the child, family and clinicians are clear about the goals.
Goals should be written in a way to ensure the goal can be measured, including a timeframe for review.
3. Goals are functional

Functional goals should reflect real-life tasks and activities that are important to the child, such as the child being able to transfer out of bed, put their socks on, ride their bike to school or play a particular activity with their friends.
Functional goals are not focussed on impairments, such as improving strength, endurance, sensory processing or joint range of movement.
4. Goals are achievable

Goals should be incremented according to the child’s ability, and the resources available to support goal practice.
It is important to acknowledge the goals and dreams of the child and family, but also important to ensure that children and families have enough understanding about their child’s prognosis and current ability to set attainable short term goals for intervention.
5. Goals are communicated to the family

Goals should be documented and a copy of the goals should be given to families.
Clinicians can discuss with the child and family what format the goals should be provided in to suit the family best, and where a copy of the goals will be stored to remind the child and family of the current goals.
6. Goals measured at the beginning and end of intervention

The clinician should measure goal performance at the beginning and end of the intervention. A review of goal performance and progress should be carried out at each intervention session to ensure the clinician is aware of any progress or changes in goal priorities. Formal goal measurement tools, such as the COPM or GAS may be used to measure goal performance if available.
INTERVENTION
7. Goal observed to determine goal limiting factors

The clinician should fully understand the child’s current ability to carry out the goal. This may include observation of the child attempting their goal to identify goal limiting factors, or discussion (if the goal is not able to be observed). Clinicians should consider both task and environmental factors that may be impacting goal achievement. This may include a discussion with the child and family regarding social and environmental supports and barriers to the child’s participation in their chosen goal.
Observation of the child attempting the goal should be done at each review or intervention session to enable the clinician to understand current goal limiting factors as the child’s skills progress, and adapt intervention plans accordingly. Individual factors, such as weakness or poor endurance may be limiting goal achievement, and these should be considered within the context of the goal, rather than isolated as the primary focus of intervention.
8. Targets the client's chosen goals

Intervention and home program should include direct practice of the child’s goals. This may include direct practice of the whole goal, as well as discussion about improving goal performance and when and where home practice of the goal will occur. It is recognised that it is not always possible to spend a whole session practicing the child’s goals, and that the child’s motivation, behaviour and potential distractions within the setting may limit capacity to do so.
9. Involve whole task practice

Therapy is most likely to lead to goal achievement when the focus of intervention is on whole task practice. When the aim of intervention is to achieve a functional goal, the focus should not be on underlying impairments, although consideration of underlying impairments may be included during goal practice. If practice of the whole goal is not possible, part task practice can be undertaken in order to work towards practice of the whole goal.
10. Challenging but achievable

Intervention should be set at the ‘just right challenge’. That is, intervention should be challenging enough that the child makes progress towards goal achievement, but allows for small successes to maintain motivation and limit frustration.
11. Maximizes learning through problem-solving and feedback

Child-led problem solving during goal practice can maximise learning and improve self-efficacy. A key to problem-solving can be the clinician ‘asking’, rather than ‘telling’ the client what to do. Therapists can prompt the child to evaluate their own success, and in this way encourage autonomy (rather than the client feeling they need feedback from the therapist). For children who have difficulty evaluating their own performance, providing feedback can be an important part of learning a new task or skill. Feedback can be provided both verbally and non-verbally.
12. Enjoyable and motivating for the child

Opportunities for the child to gain a sense of achievement and have fun are provided throughout the session. If the child is crying or distressed, the clinician stops to comfort the child and changes the intervention to match the child’s needs and preferences.
13. Involves a high enough dose of practice

The clinician considers the dose of intervention that is likely to lead to goal achievement when selecting interventions, and ensures this dose is realistic and achievable for the child and family. Whilst there may not be specific guidelines regarding dose available for all interventions, consideration of dose, and education to families regarding impact of dose of outcomes on goal achievement is important.
14. Carried out in the home or community

Clinician makes an effort to ensure intervention and goal practice is carried out in real life settings that reflect where and when the child wishes to carry out their goal. When this is not possible, practice should occur within an environment that simulates real life as much as possible. Clinicians can plan with the child and family how and when practice can be undertaken during the family’s daily routine.
15. A client-centred home program is provided

An individualised, client-centred home program is developed in conjunction with the child and family, including realistic plans for when and where practice can occur. A copy of the program is given to the family.
16. Parents/significant others are involved in intervention

Clinicians should discuss the benefits of parent/family supported practice of goals and seek to ensure that families have the skills and knowledge to support home practice.
17. Chosen interventions are supported by current evidence

Clinicians should use their knowledge of evidence based interventions to ensure that interventions that are not appropriate for the child’s age, ability or goals are not used.
Selected intervention should align with the best practice evidence, as identified in clinical practice guideline recommendations 10 to 13, which outline specific interventions that can be used when the goal is related to mobility, hand use, self-care or participation in leisure activities.
Clinicians should empower families to understand that interventions that are not appropriate for the child should not be attempted (given the time and effort required that is unlikely to lead to goal achievement).
THROUGHOUT SESSION:
18. Engages the child and family

Building a strong relationship with children and families is a key to success of an intervention. Clinicians should take time to get to know individual children and families and build a trusting relationship.
This may include understanding what the child and family enjoy doing, and understanding the time, supports and resources available to the family.
19. Communicates effectively with the child and family

The clinician builds rapport and maintains effective communication with the child and family throughout intervention.
The clinician responds to the changing needs of the child and family from one session to the next, including adapting sessions and offering support tailored to individual family needs (for example, phone, email or telehealth support between sessions).
20. Communicates effectively with the broader team

The clinician maintains effective communication with the broader team throughout.
This includes ensuring team members work towards goals that the client has prioritised, and intervention plans are shared to decrease the burden on families. At times, this may mean some disciplines are more or less involved in interventions, depending on the current goals of the child. The broader team may include health professionals, extended family members, support workers, education professionals and others who play an important part in the child’s life.
21. Shares knowledge and empowers family decision making

Clinicians should share their own knowledge and expertise, including their knowledge of current evidence regarding interventions. Clinicians should then encourage families to use this information to make their own decisions about intervention options they feel are most appropriate for their child and family at that point in time. Clinicians should work towards empowering families to make decisions without relying on professionals, and therapists should respect child and family decision making in a non-judgemental manner.
Below can be used to discuss skills, identify areas for improvement and make an action plan for change:
If you have any feedback regarding this tool or would like to reach out to the team who created this tool please contact remy.blatchwilliams@cerebralpalsy.org.au