PT for Preemies Involving Families and other Team Members Presented by Ann Barton, PT, MS, PCS & Suzanne English, MA

OBJECTIVES Will identify 3 key points of immature systems related to the last 12 weeks of fetal development. Will identify one fact related to preterm birth. Will identify 1 advantage and 1 disadvantage of 2 commonly used assessment tools. Will state 3 benefits of tummy time. Participants will identify early intervention strategies based on their role in EI.

What is preterm birth? Babies born before 37 completed weeks of pregnancy are called premature. About 12.5 percent of babies (more than half a million a year) in the United States are born prematurely. Preterm birth (<35 weeks' GA) occurs in 26% of twins versus in 3% of singletons. March of Dimes

Who is at high risk for health problems? Infants born before 32 weeks gestational age are at the highest risk >1150 infants born in SC in 2005 fell in this category Based on percentage estimates from March of Dimes

“Just the facts ma’am” 1 of 8 babies is born premature Most preemies are born between 34-36 weeks GA (>70%) 13% between 32-33 weeks 10% between 28-31 ~ 6% before 28 weeks GA Premature birth is a serious health problem. Premature babies are at increased risk for newborn health complications, as well as lasting disabilities, Those born before about 32 weeks of gestation face the highest risk. Not only are premature babies often small and sick, but also they may look and behave very differently than full-term babies. March of Dimes

Vital Statistics for SC Preliminary 2005 Data * 55,333 live births ~ 7193 premature births (1/8) 5035 born between 34-36 weeks 935 born between 32-33 weeks 719 born between 28-31 weeks 431 born before 28 weeks GA *National Center for Health Statistics 2006

What systems are immature at ~ 28 weeks EGA? Cardiopulmonary and Circulatory System Musculoskeletal System Integumentary System Neuromotor system The fetal period, commencing at the beginning of the eighth week, is characterized by continued, but less spectacular, differentiation and growth. Increasing complexity of structure and function is noted, marked increase in fetal weight in the third trimester secondary to development of adipose tissue. These processes continue to varying degrees in the different systems in the postnatal period. Normal dynamics of cell growth give an orderly increase in size in three phases: initial hyerplasia (increase in cell number), hyperplasia with hypertrophy, and hypertrophy alone.

Cardiopulmonary and Circulatory System Increased airway resistance due to very small bronchi and bronchioles Ribs and sternum have less stability for the diaphragm Soon after birth myocyte (muscle cell) division decreases regardless of EGA – leading to less capillary density and limited contractile strength Low iron stores – anemia of infancy Key point; altered lung and cardiac muscle function More than 50% of the bronchi and bronchioles are <2mm. The diaphragm is the primary muscle of inspiration…when it contracts in pushes downward and causes air to flow into the lungs…

Musculoskeletal Immaturity Muscle fiber increase is incomplete and the size of the existing muscle fibers is small Muscle fiber differentiation is immature Skeleton lacks ossification of term infant Keypoint; small, weak muscles with unstable skeleton Major development of the musculoskeletal system occurs in the embryonic period. In the fetal period, development continues with increase in size and complexity of structure and function.

Integumentary Immaturity Skin is thin or absent prior to 30 weeks Allows increased evaporative cooling Less ability to protect against some pathogens Less elasticity – prone to edema Key point; increased risk for illness and injury due to less protection

Neuromotor Immaturity Limited myelination present Immature respiratory centers lead to apnea of prematurity Cerebral white matter is vulnerable to hemorrhage due to decreased regulation of cerebral blood flow Vascular bed of the retina matures between 32-40 weeks/prone to develop ROP (retinopathy of prematurity) Key point; immature central nervous system Myelination is the maturation of certain nerve cells whereby a layer of myelin forms around the axons (structural properties of the connecting fibers) allow the nerve impulses to travel faster. This maturation eventually provides for a smooth flow of neural impulses throughout the brain, which allows for information to be integrated across the many spatially segregated brain regions involved in these functions. The speed of neural transmission is an important factor, and this depends not only on the junctions between nerve cells (synapses), but also on the (axons). Critical axon structural properties include their diameters and the thickness of the special insulation (myelin) around many fibers. he part of the central nervous system (brain and spinal cord) that controls breathing is not yet mature enough to allow nonstop breathing. This causes large bursts of breath followed by periods of shallow breathing or stopped breathing. The medical term for this condition is apnea of prematurity, or AOP.

Assessment Tools Various Tools include Global - Curriculum-based Motor Hawaii Early Learning Profile (HELP) Assessment, Evaluation and Programming System (AEPS) Motor Peabody Developmental Motor Scales (second edition) (PDMS-II) Test of Infant Motor Development (TIMP) Providers use various tools, tests and measures to evaluate motor development, function and impairments in body functions and structures. Some tools are more global and look at many domains such as the curriculum-based tools and other measures of child development are specific to finite domains.

Hawaii Early Learning Profile Purpose HELP “is a widely-used, family-centered, curriculum-based assessment for use by professionals working with infants, toddlers, young children, and their families”. VORT Corporation

Hawaii Early Learning Profile HELP Advantages Comprehensive curriculum- based tool that identifies family and infant strengths and needs across many domains Assists in determining "next steps" for intervention and support Provides individualized family-centered information and support, and can be used to monitor progress.

Hawaii Early Learning Profile HELP Disadvantages HELP is not standardized or normed. It is not intended to be used to calculate a child's single-age equivalent (score or % delay). Not a single instrument intended to be used for diagnosis Although HELP was not developed as a "test", and does not have the psychometric properties to yield standardized scores, we understand the needs of programs to quantify HELP assessment information. Guidelines for determining approximate developmental age levels for the HELP Strands are available in Inside HELP, pages i.23-i.26 and, as expanded version available for download here. The guidelines are intended to enhance consistent reporting of across staff and programs. Percent delay is usually computed by comparing a child's developmental age (DA) with the child's chronological age (CA) or adjusted age for prematurity when applicable to the child and program. If this process is used with HELP, the findings should be viewed as "approximate" and used to help support informed clinical opinion rather than as a definitive "score", "age equivalent" or the sole criterion to determining eligibility i. This use is consistent with the current and proposed May 9, 2007 regulations of Part C ii. Is HELP standardized?  [Top] No, HELP is a curriculum-based assessment. It is not a standardized test. HELP can however be used to compliment standardized instruments to support "informed clinical opinion" requirements. HELP can also be used as an initial and ongoing assessment to help identify the child's unique strengths and needs, services appropriate to meet those needs, and the resources, priorities, and concerns of the family as required by Part C. Learn more. Does HELP provide a score or single age equivalent -- is it normed or standardized?  [Top] No, HELP is not standardized or normed. As such, it is not intended to be used to calculate a child's single-age equivalent (score or % delay). HELP can, however, help determine approximate or estimated developmental levels within and between major developmental domains and help document when a child is displaying typical and atypical skills and behaviors expected for his/her age. Learn more. Are there published reliability or validity articles on HELP?  [Top] HELP is a family-centered, comprehensive, ongoing curriculum-based assessment process. HELP is not a single instrument, is not intended to be used for diagnosis, and, it is not a norm-referenced, standardized test. As such, we are not aware of specific validity research or published articles. HELP is however intended to identify family and infant strengths and needs, assist in determining "next steps" for intervention and support, provide individualized family-centered information and support, and, to monitor progress. The age ranges, skills and behaviors, criterion referencing, example observation opportunities, and developmental activities are based upon expert review and review of the literature, as well as normative data from existing standardized tests. These resources are listed in the "References" section of Inside HELP, Administration and Reference Manuel. There is also an expanding evidence base related to the benefits of using "Curriculum Based Assessments" in general, as well as the benefits of delivering family-centered services. For example: Neisworth, J.T. & Bagnato, S. J. "The MisMeasure of Young Children: the Authentic Assessment Alternative". Infants and Young Children, 17( 3):198-212, 2004. Additional journal articles that address importance of family involvement and have included using HELP in their studies include: 1. Mary Pat Moeller, M.P. "Early Intervention and Language Development in Children Who Are Deaf and Hard of Hearing" Pediatrics, Sep 2000; 106: 43. 2. Coplan, J. Jawad, A.F., "Modeling Clinical Outcome of Children with Autistic Spectrum Disorders. Pediatric 2005:116;117-122 3. Belcher, H., Butz, A. M., Wallace, P. et. al. "Spectrum of Early Intervention Services for Children With Intrauterine Drug Exposure." Infants & Young Children. 18(1):2-15, 2005. Learn more. Why do I need Inside HELP (#159) for birth to three assessment?  [Top] Inside HELP is necessary for proper use of HELP (0-3). Inside HELP provides clear procedures, criteria, and important insights on how to use HELP as a curriculum-based assessment. Learn more. Why do I need the HELP Family-Centered Interview?  [Top] This interview booklet supports your efforts to ensure a family-directed assessment of each family's concerns priorities and resources as they relate to the needs of their child. The Family-Centered Interview helps you better reflect the priorities and concerns of the family and to save you time. By using the Family-Centered Interview, you can more easily identify the needs of the child and the appropriate HELP Strands to begin your on-going curriculum-based assessment. The Family-Centered Interview helps you determine where to start within HELP. Learn more. Why do I need HELP for Preschooler Assessment and Curriculum Guide (#359) for three to six assessment?  [Top] The HELP for Preschooler Assessment and Curriculum Guide is necessary for proper use of HELP (3-6). It provides clear procedures, criteria, and instructional activities for using HELP for Preschoolers materials. Learn more. Do I need both #159 and #359 if I am working with children birth to six?  [Top] Yes, each of the books provides procedures specific to the age ranges covered. You need #159 for ages 0-3, and #359 for ages 3-6 years. How do the HELP 0-3 materials relate to the HELP for Preschoolers 3-6 materials?  [Top] The HELP for Preschoolers (3-6) skills are a direct and seamless continuation of the HELP (0-3) skills. Together, as a single continuum, HELP provides over 1,200 developmental skills covering ages 0-6 years. What is curriculum-based assessment?  [Top] Curriculum-based assessment provides skills that are developmentally sequenced and linked directly to curriculum. The nature of such an assessment provides more detailed steps than a standardized test. This results an effective method and structure for daily/weekly on-going assessment for identifying a child's needs, targeting or selecting next steps (objectives), and then teaching directly to those needs. What is the difference between the HELP Strands and the HELP Checklist?  [Top] The HELP Strands and the HELP Checklist (for both ages 0-3 and 3-6) cover the exact same skills, only the formats are different. The Strands are a newer design and provide a better developmental structure for identifying needs and planning next steps since the skills within each strand are developmentally sequenced (one leading to the next). The Checklist is more often used with "typically" developing children. The BCP seems similar to HELP -- what is the difference?  [Top] HELP covers detailed skills from ages birth to six years and provides age ranges for each skill (denoting when the skill typically emerges). The BCP does not provide age ranges and covers ages 1-14 years, so developmentally, the BCP starts and ends higher in terms of skills. The BCP is most often used with individuals with special needs who may be chronologically older than six years but developmentally are functioning between 1 and 14 years of age. Best Beginnings seems similar to HELP -- which do I need?  [Top] HELP and Best Beginnings are complimentary products. HELP is used for on-going assessment and direct involvement of the family in the specific HELP skills being targeted/taught. HELP is to be used as your "core" assessment tool. In a complimentary manner, Best Beginnings can help the family track what information they already have on their child (medical and developmental), and provide the parents with general information on what to expect (anticipatory guidance) regarding the next (3-month) stages of their child's development. Where can I get training on HELP?  [Top] The book Inside HELP, Product #159 is necessary for learning how to use HELP. The book provides a wealth of excellent child development information and strategies. Excellent Training Workshops that covers all the HELP materials are also available from Dr. Barbara Kuczen -- Learn more. Why is HELP so popular and widely used?  [Top] Over the past 20 years, VORT has continued to update and build upon the core 1,200 developmentally sequenced skills that comprise HELP. HELP is one of the most widely-used (if not the most widely used) curriculum-based assessments in the world. It has been translated into 8 languages. The reasons for HELP's success and popularity are most likely the breadth and detail of the skills covered, the structure of the skill domains and the Strands, the important and excellent family-centered design and support materials, and the optional and practical formats. How does HELP compare to other assessments?  [Top]

Assessment, Evaluation and Programming System AEPS Definition Comprehensive curriculum-based assessment system covering six developmental areas For use with birth to six years old Ties together assessment, goal development, and ongoing intervention

AEPS Advantages Criterion-referenced tool Comprehensive assessment; addresses the developmental areas of gross motor, fine motor, adaptive, cognitive, social-communication, and social Includes caregivers in assessment, intervention, and evaluation activities Addresses assessment, goal development, and helps select intervention content, Produces information that can be used directly to formulate goals and objectives

* Paul H. Brooks Publishing Company 2007 AEPS Disadvantages *Not yet validated for use in states that require an eligibility decision based on a standard-deviation or percent-delay determination. (research reportedly underway) Can be time consuming to administer Has very few items for young infant (recommended use for eligibility determination is to include goals from all 6 areas; use of multiple observations, reports from families and other direct testing as needed) * Paul H. Brooks Publishing Company 2007

How can early intervention help? The curriculum based assessment will help to identify child strengths, needs, services and other resources The PT evaluation will help to determine the specific systems that are rate limiters for motor development By doing an in depth clinical assessment a therapist can use his or her clinical observation skills and assess what systems are impacting the child’s ability to make steady progress. From this assessment a targeted treatment plan is developed in collaboration with knowledge from the CBA and or the motor test.

Peabody Developmental Motor Scales – Second Edition (PDMS-II) Purpose Provides a comprehensive sequence of gross and fine motor skills from which the developmental skill level can be obtained Can be used with able-bodied children and children with developmental disabilities

Peabody Developmental Motor Scales – II PDMS-II Advantages Norm-referenced Valid and highly reliable measure Discriminates motor problems from normal developmental variability i.e. those known to be “average” and those expected to be low or below average The PDMS-II is normed on children without delay and valid for determining present level of developmental eligibility.

PDMS-II Disadvantages Assesses only motor areas Not responsive to change in children with severe physical disabilities Not necessarily valid for planning intervention It is however not the best tool for for planning intervention. Has poor concurrent validity with the BSID-II (i.e. there are potential differences in outcome for some children using these tests) Differing outcomes can affect eligibility in some states;

Test of Infant Motor Performance TIMP Purpose A test of functional motor behavior in infants between the ages of 34 weeks postconceptional age and 4 months post-term. Constructed to assess postural control needed in age-appropriate functional activities involving movement Intended to signal developmental deviance at an early stage so that effective intervention can prevent serious impairment.

TIMP Advantages Discriminates among infants with varying degrees of risk for poor motor outcome Predicts 12-month motor performance with sensitivity 92% Can be used in the special care nursery and in community-based programs Looks at quality of movement in a functional context versus just skills Useful for planning interventions for high risk infants or infants with neurological conditions

TIMP Disadvantages Targets a very finite population Designed to be administered by therapists with close contact and personal emotional involvement with the babies.

Early Infant Assessment Muscle tone Development of reflexes Quality of movement responses State organization Postural control From a movement perspective the above areas represent a comprehensive motor-based evaluation. For the young infant the timing of the assessment can be important to optimize peformance Scheduling between feedings is important so as to capture the most active time for the infant.

Tips to Remember Defining the eligible population is an ongoing challenge Results of assessment tools can be informative but do not replace clinical judgment Scales measuring motor development are one component of a comprehensive evaluation Some tools may underestimate the degree of delay present Use of a corrected age for interpreting an assessment varies among institutions. Sometimes the correction can artifiicially inflate assessment scores and disguise developmental delays. The experienced therapists must be aware of quality of movement patterns and subtle neurologic deviations.

What we know about the premature vs. term Infant Globally displays hypotonia Decreased flexion patterns and midline orientation due to < physiological flexion Presents w/extension and abduction patterns Those infants who have been on mechanical ventilation may show hyperextension of the neck and trunk arching Strong physiological flexion Mild flexion contractures that gradually reduce Presents with flexion and adduction patterns Spontaneous movements may be limited by strong physiological flexion The level of hypotonia is directly related to the degree of prematurity. For example the infant born at 28 weeks GA or earlier shows greater ROM and flexibility than infants born at later gestational ages. The force of gravity against weak muscles reinforces extension patterns. As the premature infant develops flexor muscle tone increases but not to the degree of the term infant. This lack of flexor tone does not offset the natural progression of extension tone and leads to an imbalance between flexor and extension muscle groups. This imbalance can interfere with midline head control, sitting balance, reaching skills, and bilateral coordination in addition to feeding skills. P 91 Tecklin .The child with low tone has muscles that are slow to initiate a muscle contraction, contract very slowly in response to a stimulus, and cannot maintain a contraction for as long as his 'normal' peers. Because these low-toned muscles do not fully contract before they again relax (muscle accommodates to the stimulus and so shuts down again), they remain loose and very stretchy, never realising their full potential of maintaining a muscle contraction over time. " Recognizing hypotonia, even in early infancy, is usually relatively straightforward, but diagnosing the underlying cause can be difficult and often unsuccessful. Wikipedia

Development During the First Quarter Emphasis on functional head control At birth, righting is intact with support in upright Head turning typically in place in supine Lots of stretching, kicking and thrusting movements of the extremities Lots of turning and twisting of the head and trunk Due to the predominance of flexion there is resistance encountered when the newborn infant’s extremities are moved into extension. Typically the infant’s upper and loew extremities are held in a symmetrical posture of acute flexion the first few days after birth . This acutely flexed posutre is normal but gradually wanes. By the end of the first quarter the infa’t’s feet and hands are no longer held off the support surface. This change is thought to result form both gravity and active extension movements. Infants are most active prior to feeding . The frequency and degree of movement is related to the “state of the infant”. Not uncommon for an infant to roll from supine to sidelying in the first quarter. (P10 Tecklin 3rd edition) By the end of the first quarter the ifnat has made progress toward conquering the force of gravity

Supine The term infant typically lies in supine with head turned to one side Physiological flexion dominates the upper and lower extremities. Preemies may need positioning to bring the arms and legs from lying flat against the floor. Supine allows the child’s head to be supported so that nearby activities can be see nand watched . Child must move against gravity to reach or kick. This causes weight shifts and helps to develop balance responses. Preemies many times lack adequate muscle tone and need positioning to bring the the arms and legs from lying flat against the floor.

Low Tone vs Term The term "physiological limitation of motion" should not be confused with flexion contractures in mature joints. It is secondary to restriction of motion generally (ie, in utero), especially in the third trimester. Birth brings release from constraint and freedom of movement. Motion into extension evolves without need for intervention. the premature infant may show no limitation and hypermobility of most joints. .The child with low tone has muscles that are slow to initiate a muscle contraction, contract very slowly in response to a stimulus, and cannot maintain a contraction for as long as his 'normal' peers. Because these low-toned muscles do not fully contract before they again relax (muscle accommodates to the stimulus and so shuts down again), they remain loose and very stretchy, never realising their full potential of maintaining a muscle contraction over time. " Recognizing hypotonia, even in early infancy, is usually relatively straightforward, but diagnosing the underlying cause can be difficult and often unsuccessful. Wikipedia

Sleep position impacts head shape Infant sleep position impacts the development of head shape. The movement toward supine sleep has led to redefinition of normal head shape for infants in the US. Historically an elongated head shape was the norm. This has changed to a more brachycephalic shape. The American Academy of Pediatrics’ Back to Sleep program back to sleep campaign has led to a dramatic risk in the incidence of torticollis. Preemies are more prone to positional plagiocephaly. This is due to positioning limitations, muscle tone abnormalities, nursing care practices and secondary to medical treatment.

Prone – Baby’s First Work Prone Positioning Promotes Strengthening of back and neck extensors Weight bearing through the hands Focusing at close range Movement exploration Lateralization and cross lateral movements The ability of the infant to lift it’s head depends on the balance of the flexors and extensors. Pushing up on elbows and falling happens frequently and helps to straighten the elbows from acute flexion and also strengthens the upper trunk musculature. Infants who sleep in a supine position are not in the appropriate position upon awakening to achieve these skills spontaneously. Without adequate prone time, the antigravity motor patterns may be underdeveloped. When the infant is then placed in prone, it is an uncomfortable position and the infant will often fuss and cry. The parents' response is to then say that their infant does not like this position, and therefore they may not provide prone time during the day.

Early head lifting

Tummy Time Prone positioning for play, even in small amounts, may relate to faster achievement of developmental milestones.

Arching vs prone on elbows

Limited Prone Positioning Poor head control, Flat spots on head Low energy Hands fail to open routinely Delayed visual exploration Mobility with substitute patterns Immature development of righting reactions Delayed ability to cross midline Limited prone time as an early infant can lead to difficulties in other developmental areas. In addition to improving head control early on prone time also leads to exploration of toys and textures etc. It also promotes the eyes working together when focusing. Some of the substitute patterns that can be seen as related to limited prone positioning include overuse of rolling to reach (i.e. avoiding the head against gravity) scooting backwards in supine, bottom scooting to avoid weight through the hands. Some children spend too much time in a carrier and the seats may limit locomotor ex0plorations and perceptual development. Righting reflexes can be delayled, there can be difficulties crossing midline, and there is evidence of difficulties with comprehension, attention, organization, communication reading and writing skills. There is a release of brain chemicals during crawling that decreased stress chemicals in the blood… Positional plagiocephaly is seen more with preemies due to their weak muscles and delayed mobility. Many times they overuse supine and end up with some Flattenend areas. Sometimes use of a DOC band is indicated.

Goals of therapeutic handling Decrease hyperextension of the neck and trunk (in supine the hip and knees are gently flexed) caution is taken to avoid hyperflexion of the neck Sidelying is also used to reduce neck and trunk hyperextension and promote normal muscle tone and promote proximal stability; Reduce elevation of the shoulders (bring hands to buttocks) Promote an alert calm behavioral state

First Quarter Activities In supine encourage eye contact, reaching, sound imitation; use blankets as needed for extremity support Carry in ways to promote head control Supported sit with trunk control Tummy time (family on floor) Strengthening through pull-to-sit

Carrying to promote head control Carrying is a great way for parents to play with their child and can usually be easily weaved into the child’s daily routine. Developing the ability to hold the head upright and see what is around them helps to provide movement experiences and shifting body weight with support from the caregiver. The child learns to control the head and body. Optimal positioning includes tucking the chin and maintaining the head upright and in line with the body. The shoulders should be down.

Prone Play Suggestions Provide prone or sidelying playtime daily (*15 minutes/day) Parent can lie supine with infant prone on parent’s chest to interact Parent can place infant on table and sit within vision range while supervising for safety Use blanket roll under chest for young infant/Use mirrors Most interesting object is parent’s face • Provide supervised prone or side-lying playtime, daily.• Begin with 15 minutes per day and increase by 1 minute per week.• If infant does not initially like being in prone position, place blanket roll under its chest so it can see beyond the floor and then decrease the thickness over time as the infant's skills progress. This allows the infant to work on head control as well as upper body strength while he/she is in a more functional position for visual stimulation and play activities.• Parent can lie supine with the infant prone on the parent's chest to interact with the infant.• Parent can place the infant in prone position on a table or in an infant seat and then sit within the infant's range of vision while keeping a hand ready for safety.• Put interesting objects (e.g., toys, pictures, or even goldfish in a bowl) in the infant's visual field. Remember that the most interesting object to an infant is the parent's face. J Perinat Educ. 2004 Winter; 13(1): 10–20. doi: 10.1624/105812404X109357. Copyright 2004 A Lamaze International Publication

Development During Second Quarter Roll from supine to prone likely accidental early in the second quarter Body schema improves with lots of exploration of hands and feet in supine Movement by bridging or crawling Development of sitting with support The second quarter is characterized by great strides in combating the force of gravity. The infant begins the quarter by keeping the head aligned and ends the quarter by being able to sit alone for brief periods and push up onto hands and knees. These are important milestones on the way to independence. Infant makes great strides in conquering the force of gravity…Frequent lifting of legs and reaching for the feet is a precursor to rolling. Consistent rolling from supine is not in place yet the Lifting of the legs and then the weight of the legs can turn the baby to sidelying. A supportive environment allows for increasing elevated and vertical postures. Baby has developed more lateral flexion through the trunk and may play in sidelying

Second Quarter Activities Reaching acts in sidelying Encouraging lifting legs in supine & rolling Encouraging pivoting in prone and playing on extending arms in prone (head up to 90 degrees) Provide time for play in supported sit with fading assist Look for increased activity in supine Baby may start shifting weight while in prone but task skill difficult and may revert to forearms to reach for a toy. Look for bearing weight on open hands. Setting up the environment for movement and manipulation of toys is important in this phase. In sitting can put toys slightly outside of base of support to encourage reaching outside his/her “limit of stability” in sitting.

Rolling w/extension pattern This is a picture of the “archer” as his older brother helps him roll to sidelying. He lacks the use of a flexion pattern in that he initiated the roll using head and neck extension.

Low tone features Prop sitting is a second quarter activity. As you can see this child displays some low tone facial features with open mouth posture. His trunk lacks a balance of flexion and extension for upright control. He is not yet really demonstrating a typical 5 month prop sitting posture.

Development During Third Quarter Constant movement Supine preference decreases Pivoting in circles on the tummy Unsupported sitting Exploration paramount; leads to pulling up into kneel and possibly stand by end of third quarter Some infants use rolling but most will creep on hands knees During the third quarter the infant become mobile and develops the ability to move about the environment. Sitting unsupported can last for 30 minutes so it is the most functional position. Hands are engaged in play. Look for movement from sitting to hands and knees by end of third quarter. Will see lots of rocking on hands and knees. This provides sensory input to the extremities and vestibular apparatus. Some children may still use their lower extremities a lot for stability. If they are slow to make transitions out of sitting this is where some get stuck and compensatory patterns follow such as bottom scooting and hitching. What they are not doing if this happens is transferring weight from their buttocks to their hands. Some children may assume bear walking which requires more hip control. They may get into standing and then find themselves in the dilemma of standing and not know how to get down. Relying more on upper extremity strength at this stage . Lots of sensory input provided in this phase. Bouncing in stand gradually gives way to cruising . Look for lots of transitions and decreased use of supine.

Third Quarter Activities Need to see lots of movement during this time with transitions from sit Reaching out for toys while holding four point Prone mobility is important to encourage; this movement can be assisted Can encourage modified tall kneel This is where some children get stuck in sitting. They keep a wide base of support with stiff legs and don’t initiate transitions onto their hands. If they don’t get enough transition opportunities during this time compensatory patterns can develop such as overusing rolling and bottom scooting.

Rocking in four point In the third quarter we are looking for some form of prone mobility to develop . This child is pulling into a modified four point and rocking but not yet ready to creep. His shoulders are internally rotated which is an early hands and knees position.

Development During Fourth Quarter Prone and supine are mostly transitional Hands and knees is the basis for creeping Assumes and maintains tall kneeling Cruising to early walking Plantigrade creeping on extended arms and legs becomes part of the repertoire Walking at last The baby has previously relied on the upper extremities for a large portion of support in upright but can now use the lower extremities for support. See a lot of lateral flexionin upright with stiff-leggedness in early walking. Walking progresses to become smooth and coordinated after the first year. Within a few short months after walking the child can get up into a plantigrade position and assume standing. With increased time in standing the child develops the ability to balance and will let go of support and begin to walk.

Fourth Quarter Activities Encourage upright mobility with fading support as needed Identify furniture for pulling up and cruising Promote play in stand without supports Identify environmental safety hazards for caregivers Identify opportunities to practice upright with caregivers The child spends little time on the tummy or back at this stage. Some may become very adept creepers and even the onset of walking may not preclude some preferences to continue creeping for a few months. Most children do some plantigrade creeping although many may use this mostly for transitional work.

Early Walking Picture Child just started walking in early May. He is a 24 month preemie born ~ 3 months early. History of slow progress with some medical complications. As an early infant he displayed marked overuse of extension (toe standing) and marked decreased flexor control (very late rolling from supine) Strengths included many opportunities for floor play on a regular basis, stay at home mom, older siblings, and no use of positioning equipment. He is currently not overusing extension and at this time has developed a relatively good balance of control for early walking and fair plus control in independent standing despite his delayed milestone development.

After walking Getting to stand without supports Arms move down from high guard to low guard Child practices getting up and down from furniture Creeping up and down stairs Narrowing base of support in walking Sometimes preemies actually accomplish some of these feats prior to walking.

Continuum of caregiver involvement Noninvolvement Passive involvement Information seeking Partnership/reciprocal interaction Service coordination Advocacy The family centered approach not only expands the role of service providers, but it also expands the role of the family. Parents are asked to learn new skills Related to taking care of a child with special needs. The extent to which families can participate varies. They can select the way in which in way they will be involved. When families are either not involved or passively involved some models may work better than others. Consultative models may work best when families and providers have reciprocal interaction. What is known is that one size does not fit all. If services are implemented and there is poor team collaboration for whatever reason, it will serve the family best if there is flexibility for additional team members to provide direct serve when needed. Otherwise a child may not receive the services and strategies necessary to support the IFSP.

What does the evidence tell us about PT Research in early intervention is limited Problem of withholding intervention diminishes PT interventions do serve to enhance parent responsiveness to children Communication, coordination and education/instruction are relevant components in early intervention

What does the evidence tell us about effectiveness of family-centered care? Evidence is scarce Difficult to identify literature that has examined family-centered care Studies vary in how family centered care is defined

What impacts child skill development and adjustment? The family’s ability to build support networks Family participation Quality of the home environment Maternal mental health Quality of parent-child relationships Family stressors There is a current belief that parent should be actively involved in the therapy regime for their children and should be working as equal partners. There are two main arguments for involving parents. The first involves child functioning. Parents can play a critical role in the transfer of home recommendations in to the daily function of the child. The second factor is the effect this has on the role of the parent. Those who participate are likely to develop more insight in the abilities of their child and thus a more realistic view of their child’s potential. Most research has focused on child functioning. Parent functioning has however received little attention. Although parental participation is generally thought to have positive effects , negative effects can occur. Involvement can become an extra stress factor for parents who already have to deal with the difficulties of raising a child with special needs. Literature review conducted over the last 2 0years. Three factors were found to influence the effect of parental participation. First – the relation between the parents and therapists b) Exchange of information and equal involvement are important c) – Therapists have to make an effort for parent to feel involved---leads to compliance Second – Focus on family functioning and functioning of the child Third - contacts during therapy sessions …leads to decreasing parental stress If parental participation is to become a regular part of the PT program…attention needs to be paid to parental well being…

Strategies to encourage family involvement Assess the family’s needs Educate Communicate openly and listen Involve other family members/caregivers as relevant Collaborate (what’s working/what’s not) Reassess and refocus After taking stock of the family’s routines and overall situation we need to educate parents and provide them with accurate and current information. We can not however start out expecting an actively participating parent. Families are at different points when we begin our service. Stress levels can be compounded due to many demands on time, finances and patience. If this happens intervention effectiveness is lessened regardless of the model. Direct handling may be a a good route early on as we lay the ground work to progressively prepare parents and caregivers to incorporate more of a home program. We need to constantly think about our role within a system of care. Empowering parents is critical to the early intervention process because parents ultimately are the ones who will facilitate their child’s progress. Even though as PTs we work a lot with our hands it is our brain that makes the difference. When we are successful in teaching the parent how to work with their child the child is more likely the develop the necessary skills

Role of Families Nearly all empirically supported treatments include a parent component. It is well established that parents can learn and successfully apply skills to change the behavior of their children.

Who should serve the child? No one discipline can provide services that incorporate all child and family needs Effective interventions require multiple levels of collaboration Professionals are needed who are adequately prepared to serve in the expanded scope of practice in early intervention

Children need time for practice! It takes 10,00 hours of dedicated practice to become an expert…. Providing services in natural environments is supported by principles of motor learning. Practice and repetition of activities in natural contexts and settings are more effective for learning and generalization. Collaborating to ensure that the treatment plan includes sufficient practice is important to motor development.

Preemie Case Study Sarah is a 12 month preemie with an adjusted age of 9 months. She is healthy, lives with her parents and is on a regular sleep/wake cycle. She is a good eater. There is no extended family in state. Both parents work .(mom works part-time time on the night shift) Sarah has a history of not liking prone and does not yet have a form of mobility. She loves to sit. Sarah keeps her legs stiff for stability and does not move out of sitting. When held in stand she toe stands. There is an exersaucer in the room and lots of toys. Toys are always very near Sarah during play when Mom sets up the floor time. Sarah rolls very little to get off her tummy except when she is really upset. She can not move in prone other than to roll occasionally . Usually when she cries in that position Mom picks her up.. Sarah can achieve a calm behavioral state but she has extreme state reactions to movement in space (transitions out of sitting). (Dad helps w/ caregiving in the mornings until mom gets home around mid-morning. Most weekdays are spent in the apartment during the work week so mom can sleep some during the day. Both the EI and the PT recognize, that Mom gets stressed when Sarah cries. There is slow progress with transitions. What are the next possible steps for all parties? (Mom, PT, and EI?)

Bibliography Hummel, P., Fortado,D, Advanced Neonatal Care. 2005;5(6) Impacting Infant Head Shapes Jansen, Lucres MC., Ketelaar, M., Developmental Medicine and Child Neurology 2003 45:58-69, Parental experience of participation in physical therapy for children with physical disabilities. Scales,L., McEwen, I. Murray, C. Fall 2007 pp 196-202, Parent’s Perceived Benefits of Physical Therapists’ Direct Intervention Compared with Parental Instruction in Early Intervention. Tecklin, J., Pediatric Physical Therapy, Third Edition. Vort Corporation Website http://www.vort.com/products/help_overview.html March of Dimes Website Factsheet http://www.marchofdimes.com/professionals/14332_1157.asp Garber, J., APTA 8th Annual Advanced Clinical Practice, High risk Infants: Developmental Evaluation and Intervention in the NICU Assessment, Evaluation and Programming System,