Best Practice in Developmental Skills Training in Early Intervention

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Early Intervention

Early intervention is a federal program that provides education and therapeutic resources to families with children 0-3 with developmental delays.  Services covered in early intervention can include speech, OT, PT, vision, nursing, hearing and assistive technology.  Evaluations are performed in a natural environment for the child such as the home or daycare. 

Family Centred Care

Family centred care empowers families to be the decision-makers for their child’s goals and interventions.  In this approach, the therapist works as a coach and collaborator with the family and not one of expert knowledge. In a family-centred model, it is important to first discuss the family’s comfort and difficulties they might be experiencing.  Understanding their concerns and hopes will help shape goals and specific intervention tasks.  The therapist will begin by observing the child performing specific tasks to determine what they are able to do, how much assistance is required, what is inhibiting the task and what adaptations can be made.  The therapist and family then collaborate by discussing ways to practice the tasks within the child’s daily routine.  Providing home exercise program via video or written instruction are helpful reminders for families.

GAME INTERVENTION

GAME is a goal (G) based activity (A) with  intensive motor training (M) in an enriched environment (E). (GMMASH) This program is used in early intervention infants at high risk for CP.  A recent systematic literature review showed GAME intervention prior to 5 months old to be superior to standard intense care. (DAMIANO) This intervention is comprised of three factors:

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

Goal Oriented

The therapist and family collaborate to create motor goals based on the assessment and the parental knowledge of the child’s play preferences.  The goals are the focus during practice sessions and for the home program.  Task-specific training should incorporate successful trials as it motivates the child towards continued repetition. Optimal outcomes are seen through repetition and intensity. Goals and tasks may be adapted to achieve success with the whole or portions of the task.   Once they are successful in a specified task, the motor challenge is increased 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.

Damiano et.al, 2021 described the following characteristics of family centred goals:

• 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

• 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.

• 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.

• They always emphasize positive actions, identifying what the child or family can do, rather than what they cannot do.

• Active voice is preferred to passive voice; expressions that imply involvement and active participation of the child/family.

Early Weightbearing

Early weight bearing and sit to stand from the parents’ lap is a routine GAME intervention even if they specified in the goal.  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 early activation of muscles in the leg with the facilitation of concentric and eccentric exercises.  For children with CP, routine standing practice could assist with impairments such as weakness and selective motor control.

REACHING AND GRASPING

For infants who are anticipated to have a delay, grasping and reaching a variety of objects are standard parts of motor training within GAME intervention.  Providing opportunities to use hands through experience is critical to optimizing hand function.  In cases where asymmetrical hand function is present, modified constraint induced movement therapy and/or bimanual training can be used. Research shows infants with unilateral CP who performed CMIT during their first year of life had a positive influence on their hand function.

HOME PRACTICE

GAME intervention emphasizes the importance of a home program that the infant can do independently and activities the family can do with them as well.  Written instructions with pictures are provided that relate to the families goals, weight-bearing and reach and grasp activities.  Home programs can be updated as goals are reached.

PARENTAL EDUCATION

In GAME intervention, the therapist acts as a coach enhancing the parents knowledge of their child’s development and how best of enhance it. Varying natural learning opportunities are emphasized such as:

• parent participation is essential,
• the use of repetitions
• independent play

Coaching is done in a positive and warm context.  As the child progresses through a skill, coaching is then geared towards parents devising ways to increase the challenge.

ENVIRONMENTAL ENRICHMENT

All visits are performed in the family’s home during GAME intervention with an emphasis on setting up enriched motor play environments.  An enriched environment allows for exploration, task success and self-generated movements.  Toys or equipment that the family already has is used with a careful selection of what is needed to match the desired motor task. Morgan et al. 2021 described ways to enrich the environment:

• 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.

• Social interaction with sibling and extended family members are encouraged as well.  These addition family members can participate in therapy sessions which will promote family acceptance, knowledge and wellbeing.

GAME therapists visit weekly initially and then alter frequency based on the family’s availability, resources and preference.  In general, visits are between 60-90 min.

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