Best Practice in Developmental Skills Training in Early Intervention

Original Editor - Robin Tacchetti based on the course by Pam Versfeld
Top Contributors - Robin Tacchetti, Robin Leigh Tacchetti, Tarina van der Stockt, Kim Jackson, Ewa Jaraczewska, Naomi O'Reilly, Jess Bell and Olajumoke Ogunleye

Early Intervention

Early intervention programmes provide education and therapy resources to families of children with developmental delays aged three years and under. Services included in early intervention programmes might include speech therapy, occupational therapy, physiotherapy, vision, nursing care, hearing and assistive technology. Evaluations are typically performed in a natural environment for the child such as the home or daycare. Please watch the video below from the Allen County Board of Developmental Disabilities to quickly learn more about early intervention.

Family Centred Care

Figure.1 Infant on all Fours

Early intervention services are geared towards empowering families to be the decision-makers for their child’s goals and intervention. In this family centred approach, the therapist works as a coach and collaborator with the family, rather than as a knowledge expert who makes all the decisions. Initially, the family and therapist will discuss the family’s circumstance's and any difficulties they may be experiencing. Understanding their concerns and hopes will help shape goals and specific selection of intervention tasks. During the assessment, the therapist will observe the child performing specific tasks to determine what they are capable of, their strengths, how much assistance is required, what is constraining the task and what adaptations can be made to allow the child to succeed. The therapist and family then together decide on ways to practise the tasks within the child’s daily routine. Providing home exercise programmes via video or written instruction can be helpful reminders for families.

Goals

Figure.2 Infant Pulling to Stand

Dalmau et al. recommend the following when setting up goals for the child:

1. "They are functional and needed for the child and family to be able to participate in the activities that are important for them. The goals are always established on the basis of what the family considers to be necessary and functional for them, not on the basis of what the professional thinks or believes to be useful or significant in their lives."
2. "They reflect real situations of daily life and routines of the families, such as having meals, baths, going to the park, etc. Often, the goals set up by developmental areas are neither contextualized nor represent situations of daily life."
3. "They describe the participation of the child and/or family in routines, which means that in the writing it is the child or family that are the “actors”, not the professionals."
4. "Their writing has to be free of jargon, using daily routines and activities."
5. "They always emphasize positive actions, identifying what the child or family can do, rather than what they cannot do."
6. "Active voice is preferred to passive voice; expressions that imply involvement and active participation of the child/family"

GAME Intervention

One early intervention approach used for infants at risk for Cerebral Palsy (CP) is called GAME: Goal based (G) activity (A) with intensive motor training (M) in an enriched environment (E). This approach has three components:

1. Goal-oriented intensive motor training
2. Parent Education
3. Strategies to enrich the child’s motor learning environment

Visits are usually weekly at first, but the frequency changes according to the family’s preference, availability and resources. A GAME intervention session usually lasts between 60-90 minutes. A recent systematic literature review showed that GAME interventions for infants prior to 5 months old are superior to standard care.

Goal Oriented Intensive MotorTraining

Figure.3 Infant Picking Toy from Floor

Goals created by the therapist and family are the focus during therapy sessions and for the home programme. Parent-identified goal areas are targeted for practice during the therapy session and and in a home program (HP).  

During practice of motor tasks, the therapist or parent scaffolds all motor tasks, so that the infant could always actively complete at least a part of the task. As performance improves, the challenge is increased by altering the task or environment to a new and appropriate level of difficulty.

Manual assistance is provided by the therapist and parent only when necessary for safety or to give the infant the “idea” of the movement. “Manual assistance is reduced or withdrawn as soon as the infant demonstrates self-initiated progress with the task; ensuring self-generated motor activity is the focus of all practice. Once a motor skill is learned, variability of practice is introduced to increase the complexity” and generalisation of the skill.

The task goal materialises based on the interplay of the task requirement (task demand) (T), the individual child (I)  and the environment (E) or TIE principle. When analysing the child’s performance, all three components of the TIE principle must be considered. Task-specific training should incorporate successful trials as it motivates the child towards continued repetition. Optimal outcomes are obtained through repetition and intensive practice. Goals and tasks may be adapted to achieve success with the whole task or parts of the task. Once the infant is successful in a specified task, the motor skill is challenged by building on the previously learned skill. Activities accentuate minimal manual guidance with the ability to withdraw assistance once the child is able to successfully demonstrate the specified movement or sequence.

Early Weight Bearing

Figure.4 Infant and Therapist Interacting

Early weight bearing and sit-to-stand from a parent's lap is routinely practiced in the GAME approach even if they are not specified goals. Research shows that functional weight-bearing can provide strength training and improve motor control in older children and adults with brain injuries. Upright mobility can be enhanced by the early activation of muscles in the leg with the facilitation of concentric and eccentric exercises. For children with Cerebral Palsy, routine standing practice could assist with impairments such as weakness and selective motor control.

Reaching and Grasping

Figure.5 Infant playing with toy

For infants who are at risk for developmental delay, grasping and reaching a variety of objects are standard motor training tasks within the GAME approach. 

Providing many opportunities to use hands for object manipulation through experience is critical for optimising hand function. In cases where asymmetrical hand function is present, modified constraint induced movement therapy (CIMT) and/or bimanual training can be used.

Research shows that CMIT during the first year of life has a positive influence on the hand function of infants who have unilateral CP.

Home Practice

The GAME intervention emphasises the importance of developing a home programme that provides the infant with the opportunity for independent play and plays activities with the family. Written instructions with pictures are provided that relate to the family's goals, as well as weight-bearing and reach and grasp activities. Home programmes can be updated as goals are reached. Practice schedules should also be designed based on family time constraints and available resources.

Parental Involvement and Education

Parents play an active role in selecting goals and carrying out a home program. Parents are provided with the knowledge and skills to promote and support their baby's self-initiated and generated actions, exploration and engagement with motor tasks.

Parent education as described by Morgan et al.:

“Parents are coached to identify their child’s voluntary attempts to move and self-regulate, plus understand the usual trajectory of emergent motor skills and how to stimulate progress.

Parents are trained in simple motor task analysis and coached in appropriate strategies to enhance their child’s development both at a specific goal level and in general early learning and development principles.

Parents are taught to optimise the best use of their infants’ awake time and the naturally occurring opportunities for learning. Learning optimisation included both parent-directed and structured practice of desired motor tasks, where the parent role was integral to the child’s learning (e.g. creating repetitions) and constructing opportunities for independent play (e.g. playing alone with motor enriching toys set up for the child).

Parents are encouraged to both observe the therapist eliciting a motor behaviour from the baby and to attempt it themselves. Specific feedback was given to parents to enable them to tease out why some attempts were successful for the baby and others weren’t.

As new motor skills emerged parents are coached in strategies to increase the challenge of the task; for example remove support or introduce a more complex toy.

The importance of allowing trial and error during practice is discussed and parents are encouraged to devise their own activities to enhance goal attainment.”

Environmental Enrichment

Figure.6 Parent reading to infant

Providing an enriched environment that encourages active exploration and play within the family’s home is the third aspect of the GAME intervention. Toys or equipment are used that the family already owns with a careful selection of what is needed to match the child’s abilities and interests. Morgan et al. state that the whole environment should be taken into account, which may include:

• "evidence-based early learning stimulation and role modelling to enhance cognitive and language development (e.g. reading books to children, limiting passive television watching);
• optimising sleep hygiene;

• feeding interventions (e.g. anti-reflux medications) to ensure adequate caloric nutrition and pain-free backdrops for learning."

Extended family members are encouraged to engage in social interaction with the child, as well as to participate in therapy sessions as this will help to enhance family knowledge, and promote acceptance and wellbeing. As mentioned, GAME therapists initially visit families weekly, before altering the frequency based on the family’s availability, resources and preference. 

Resources

• Cerebral Palsy Introduction
• Family Centred Intervention and Early Diagnosis
• Gross Motor Function Classification System - Expanded and Revised (GMFCS-ER)
• Early Intervention in Cerebral Palsy