The impact of severity of motor delay, timing of task mastery, and START-play intervention on the development of means-end problem solving in young children.

BACKGROUND: Children with motor delays are at increased risk for delayed means-end problem-solving (MEPS) performance. OBJECTIVES: To evaluate children with motor delays: 1) the impact of motor delay severity and MEPS mastery timing on developmental trajectories of MEPS; and 2) the effectiveness of Sitting Together And Reaching To Play (START-Play) intervention for improving MEPS. METHODS: This represents a secondary analysis from a multi-site randomized controlled trial, with blinded assessors and prospective registration. Children with mild or significant motor delays (n = 112, mean age=10.80, SD=2.59 months at baseline) were randomly assigned to START-Play or usual care early intervention (UC-EI) and assessed at five visits across one year using the Means-End Problem-Solving Assessment Tool that included three 30-second MEPS trials per visit. Task mastery occurred at the first visit the child achieved the highest level of performance in at least two of the three trials. Multilevel analyses evaluated trajectories of MEPS outcomes dependent upon the timing of MEPS mastery, motor delay severity, and intervention group. RESULTS: At baseline, children with mild motor delays demonstrated better MEPS than children with significant delays, but this difference was only observed for children who achieved mastery late. Children with significant delays demonstrated greater improvements in MEPS in the post-intervention phase compared to children with mild delays. No MEPS differences were found between START-Play and UC-EI. CONCLUSION: Motor delay severity and timing of task mastery impacted MEPS trajectories, whereas START-Play intervention did not impact MEPS for children with motor delays. CLINICAL TRIALS REGISTRY IDENTIFIER: NCT02593825 (https://clinicaltrials.gov/ct2/show/NCT02593825).

Biological and environmental factors may affect children's executive function through motor and sensorimotor development: Preterm birth and cerebral palsy.

Disruptive biological and environmental factors may undermine the development of children's motor and sensorimotor skills. Since the development of cognitive skills, including executive function, is grounded in early motor and sensorimotor experiences, early delays or impairments in motor and sensorimotor processing often trigger dynamic developmental cascades that lead to suboptimal executive function outcomes. The purpose of this perspective paper is to link early differences in motor/sensorimotor processing to the development of executive function in children born preterm or with cerebral palsy. Uncovering such links in clinical populations would improve our understanding of developmental pathways and key motor and sensorimotor skills that are antecedent and foundational for the development of executive function. This knowledge will allow the refinement of early interventions targeting motor and sensorimotor skills with the goal of proactively improving executive function outcomes in at-risk populations.

START-Play Physical Therapy Intervention Indirectly Impacts Cognition Through Changes in Early Motor-Based Problem-Solving Skills.

PURPOSE: This study tested whether the Sitting Together and Reaching to Play (START-Play) physical therapy intervention indirectly impacts cognition through changes in perceptual-motor skills in infants with motor delays. METHODS: Participants were 50 infants with motor delays randomly assigned to START-Play plus Usual Care Early Intervention (UC-EI) or UC-EI only. Infants' perceptual-motor and cognitive skills were assessed at baseline and 1.5, 3, 6, and 12 months post-baseline. RESULTS: Short-term changes in sitting, fine motor skills, and motor-based problem-solving, but not reaching, predicted long-term changes in cognition. START-Play indirectly impacted cognition through motor-based problem-solving but not sitting, reaching, or fine motor skills. CONCLUSIONS: This study provided preliminary evidence that early physical therapy interventions that blend activities across developmental domains and are supported by an enriched social context can place infants on more optimal developmental trajectories.

The Effect of START-Play Intervention on Reaching-Related Exploratory Behaviors in Children with Neuromotor Delays: A Secondary Analysis of a Randomized Controlled Trial.

AIMS: Children with neuromotor delays are at risk for reaching and object exploration impairments, which may negatively affect their cognitive development and daily activity performance. This study evaluated the effectiveness of the Sitting Together And Reaching To Play (START-Play) intervention on reaching-related exploratory behaviors in children with neuromotor delays. METHODS: In this randomized controlled clinical trial, 112 children (Mean = 10.80, SD = 2.59 months old at baseline) with motor delays were randomly assigned to receive START-Play intervention or usual care-early intervention. Performance for ten reaching-related exploratory behaviors was assessed at baseline and 1.5, 3, 6, 12 months post-baseline. Piecewise linear mixed-effects modeling was used to evaluate short- and long-term effects of the intervention. RESULTS: Benefits of START-Play were observed for children with significant motor delays, but not for those with mild delays. START-Play was especially beneficial for children with significant motor delays who demonstrated early mastery in the reaching assessment (i.e., object contact ≥65% of the time within 3 months after baseline); these children showed greater improvements in manual, visual, and multimodal exploration, as well as intensity of exploration across time. CONCLUSIONS: START-Play advanced the performance of reaching-related exploratory behaviors in children with significant motor delays.

The Effect of Early-Life Seizures on Cognitive and Motor Development: A Case Series.

PURPOSE: This case series documents developmental changes over time and in response to a novel intervention, Sitting Together and Reaching to Play (START-Play), in children with early-life seizures. METHODS: Thirteen children with early-life seizures were included from a subset of participants in the START-Play multisite, randomized controlled trial. Seven received 3 months of twice weekly START-Play intervention; 6 continued with usual care early intervention. Bayley Scales of Infant Development-III (Cognitive Composite), Gross Motor Function Measure-66 Item Set, Assessment of Problem-Solving in Play, and reaching assessments were administered at baseline, 3, 6, and 12 months postbaseline. Change scores are reported at 3 and 12 months postbaseline. RESULTS: Over time, plateau or decline was noted in standardized cognition measures; motor development improved or was stable. Children receiving START-Play showed positive trends in problem-solving (71.4%) and reaching behaviors (57.2%). CONCLUSIONS: Interventions such as START-Play that combine motor and cognitive constructs may benefit children with early-life seizures.

A model for using developmental science to create effective early intervention programs and technologies to improve children's developmental outcomes.

Children born with a variety of environmental or medical risk factors may exhibit delays in global development. Very often, such delays are identified at preschool or school age, when children are severely overdue for effective early interventions that can alleviate the delays. This chapter proposes a conceptual model of child development to inform the creation of interventions and rehabilitative technologies that can be provided very early in development, throughout the first year of life, to optimize children's future developmental outcomes. The model suggests that early sensorimotor skills are antecedent and foundational for future motor, cognitive, language, and social development. As an example, this chapter describes how children's early postural control and exploratory movements facilitate the development of future object exploration behaviors that provide enhanced opportunities for learning and advance children's motor, cognitive, language, and social development. An understanding of the developmental pathways in the model can enable the design of effective intervention programs and rehabilitative technologies that target sensorimotor skills in the first year of life with the goal of minimizing or ameliorating the delays that are typically identified at preschool or school age. Specific examples of early interventions and rehabilitative technologies that have effectively advanced children's motor and cognitive development by targeting early sensorimotor skills and behaviors are provided.

Early exploration of one's own body, exploration of objects, and motor, language, and cognitive development relate dynamically across the first two years of life.

Early exploratory behaviors have been proposed to facilitate children's learning, impacting motor, cognitive, language, and social development. This study related the performance of behaviors used to explore oneself to behaviors used to explore objects, and then related both types of exploratory behaviors to motor, language, and cognitive measures longitudinally from 3 through 24 months of age via secondary analysis of an existing dataset. Participants were 52 children (23 full-term, 29 preterm). Previously published results from this dataset documented delays for preterm relative to full-term infants in each assessment. The current results related performance among the assessments throughout the first 2 years of life. They showed that the developmental trajectories of behaviors children used for self-exploration closely related to the trajectories of behaviors they employed to explore objects. The trajectories of both self and object exploration behaviors significantly related to trajectories of children's motor, language, and cognitive development. Specifically, significant relations to global development were observed for self-exploratory head lifting, midline head and hand positioning, hand opening, and behavioral variability, as well as for object-oriented bimanual holding, mouthing, looking, banging, manipulating, transferring of objects, and behavioral intensity and variability. These results demonstrate continuity among the early exploratory behaviors infants perform with their bodies alone, exploratory behaviors with portable objects, and global development. The findings identify specific self- and object-exploration behaviors that may serve as early indicators of developmental delay and could be targeted by interventions to advance motor, language, and cognitive outcomes for infants at risk for delay. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Factors Affecting the Perception of Disability: A Developmental Perspective.

Perception of disability is an important construct affecting not only the well-being of individuals with disabilities, but also the moral compass of the society. Negative attitudes toward disability disempower individuals with disabilities and lead to their social exclusion and isolation. By contrast, a healthy society encourages positive attitudes toward individuals with disabilities and promotes social inclusion. The current review explored disability perception in the light of the in-group vs. out-group dichotomy, since individuals with disabilities may be perceived as a special case of out-group. We implemented a developmental approach to study perception of disability from early age into adolescence while exploring cognitive, affective, and behavioral components of children's attitudes. Potential factors influencing perception of disability were considered at the level of society, family and school environment, and the individual. Better understanding of factors influencing the development of disability perception would allow the design of effective interventions to improve children's attitudes toward peers with disabilities, reduce intergroup biases, and promote social inclusion. Based on previous research in social and developmental psychology, education, and anthropology, we proposed an integrative model that provides a conceptual framework for understanding the development of disability perception.

Assistive and Rehabilitative Effects of the Playskin LiftTM Exoskeletal Garment on Reaching and Object Exploration in Children With Arthrogryposis.

IMPORTANCE: Children with arthrogryposis multiplex congenita are often delayed in their development of reaching and object exploration, which can place them at risk for associated delays in motor and cognitive development. OBJECTIVE: To evaluate the longitudinal assistive and rehabilitative effects of the Playskin Lift™ (hereinafter Playskin), a novel exoskeletal garment, on reaching and object exploration abilities in children with arthrogryposis. DESIGN: Single-case ABA design with a 1-mo baseline, 4-mo intervention, and 1-mo postintervention. SETTING: Home environment. PARTICIPANTS: Seventeen children with arthrogryposis (ages 6-35 mo at first visit; 5 boys). INTERVENTION: Participants used the Playskin daily for 30 to 45 min while participating in structured intervention activities to encourage reaching for objects across play spaces larger than they were typically able to. OUTCOMES AND MEASURES: Participants were tested biweekly throughout the study with and without the Playskin using a systematic reaching assessment. Coding of reaching and object exploration behavior was performed using OpenSHAPA software; statistical analyses were conducted using Hierarchical Linear and Nonlinear Modeling software. Feasibility of the Playskin for daily home intervention was evaluated with a parent perception questionnaire. RESULTS: Positive assistive effects (improved performance when wearing the Playskin within sessions) and rehabilitative effects (improved independent performance after the Playskin intervention) were observed with increased active range of motion, expanded reaching space, improved grasping with the ventral side of the open hand, and greater complexity and multimodality and intensity of object exploration. CONCLUSIONS AND RELEVANCE: The Playskin may be a feasible, effective assistive and rehabilitative device to advance object interaction and learning in young children with arthrogryposis. WHAT THIS ARTICLE ADDS: The novel exoskeletal Playskin garment improves reaching and object exploration in young children with arthrogryposis.

A Novel Means-End Problem-Solving Assessment Tool for Early Intervention: Evaluation of Validity, Reliability, and Sensitivity.

PURPOSE: To evaluate validity, reliability, and sensitivity of the novel Means-End Problem-Solving Assessment Tool (MEPSAT). METHODS: Children with typical development and those with motor delay were assessed throughout the first 2 years of life using the MEPSAT. MEPSAT scores were validated against the cognitive and motor subscales of the Bayley Scales of Development. Intra- and interrater reliability, developmental trends, and differences among groups were evaluated. RESULTS: Changes in MEPSAT scores positively related to changes in Bayley scores across time for both groups of children. Strong intra- and interrater reliability was observed for MEPSAT scoring across all children. The MEPSAT was sensitive to identify change across time and differences in problem-solving among children with varying levels of motor delay. CONCLUSIONS: The MEPSAT is supported by validity and reliability evidence and is a simple tool for screening early problem-solving delays and evaluating change across time in children with a range of developmental abilities. What this adds to the evidence: The novel MEPSAT is supported by validity and reliability evidence. It is sensitive to detect problem-solving differences among young children with varying motor ability and to capture changes in problem-solving across time. It requires minimal equipment and time to administer and score and, thus, is a promising tool for clinicians to screen for early problem-solving delays or to track intervention progress in young children with or at risk for problem-solving delays.

START-Play Physical Therapy Intervention Impacts Motor and Cognitive Outcomes in Infants With Neuromotor Disorders: A Multisite Randomized Clinical Trial.

OBJECTIVE: Our objective was to evaluate the efficacy of the Sitting Together and Reaching to Play (START-Play) intervention in young infants with neuromotor disorders. METHOD: This randomized controlled trial compared usual care early intervention (UC-EI) with START-Play plus UC-EI. Analyses included 112 infants with motor delay (55 UC-EI, 57 START-Play) recruited at 7 to 16 months of age across 5 sites. START-Play included twice-weekly home visits with the infant and caregiver for 12 weeks provided by physical therapists trained in the START-Play intervention; UC-EI was not disrupted. Outcome measures were the Bayley Scales of Infant and Toddler Development, Third Edition (Bayley); the Gross Motor Function Measure; reaching frequency; and the Assessment of Problem Solving in Play (APSP). Comparisons for the full group as well as separate comparisons for infants with mild motor delay and infants with significant motor delay were conducted. Piecewise linear mixed modeling estimated short- and long-term effects. RESULTS: For infants with significant motor delay, positive effects of START-Play were observed at 3 months for Bayley cognition, Bayley fine motor, and APSP and at 12 months for Bayley fine motor and reaching frequency outcomes. For infants with mild motor delay, positive effects of START-Play for the Bayley receptive communication outcome were found. For the UC-EI group, the only difference between groups was a positive effect for the APSP outcome, observed at 3 months. CONCLUSION: START-Play may advance reaching, problem solving, cognitive, and fine motor skills for young infants with significant motor delay over UC-EI in the short term. START-Play in addition to UC-EI may not improve motor/cognitive outcomes for infants with milder motor delays over and above usual care. IMPACT: Concepts of embodied cognition, applied to early intervention in the START-Play intervention, may serve to advance cognition and motor skills in young infants with significant motor delays over usual care early intervention. LAY SUMMARY: If you have a young infant with significant delays in motor skills, your physical therapist can work with you to develop play opportunities to enhance your child's problem solving, such as that used in the START-Play intervention, in addition to usual care to help your child advance cognitive and motor skills.

A perspective on the development of hemispheric specialization, infant handedness, and cerebral palsy.

Cerebral Palsy (CP), a common form of neurological pediatric disability, results from pre- or perinatal brain injury. Although there is growing evidence of the efficacy of motor learning-based therapies, several factors interact to produce variability in impairment and limit the effectiveness of these therapies. The variability of hand function present in children with CP indicates that a range of developmental pathways must contribute to the manifestation of individually unique characteristics of impairment. Despite two decades of progress using therapies derived from understanding the mechanisms controlling hand function, very little is known about the sensorimotor experiences occurring during development that likely shape later functional problems for children with CP. In this "perspective" paper, we propose that the study of the development of motor skills in typically developing infants may reveal experiential factors potentially important for creating remedial therapies for children with CP. Specifically, we use the development of infant handedness, a model of hemispheric specialization of function, as an example of how self-generated experiences and sensorimotor feedback can shape the development of limb control and hemispheric specialization. We illustrate how early sensorimotor asymmetries concatenate into pronounced differences in skill between the two hands. We suggest that this model of infant handedness provides a framework for studying the individual differences manifested in children with CP. These differences likely arise from aberrant sensorimotor experiences created by sensorimotor circuits disrupted by the early brain injury. We conclude that knowledge of the developmental events, including subtle motor behaviors, that shape sensorimotor pathways, can improve treatment options for children with CP.

Assessing the Validity and Reliability of a New Video Goniometer App for Measuring Joint Angles in Adults and Children.

OBJECTIVE: To assess the convergent validity and reliability of joint angle measurements from a new video goniometer iPhone/iPad application separately in adults, older and young children. DESIGN: Cross-sectional. SETTING: Child care and university environments. PARTICIPANTS: Fifty-four adults (mean ± SD=22.5±4.5y), 20 older children (mean ± SD=10.9±2.2y), 20 younger children (mean ± SD=1.6±0.8y) (N=94). INTERVENTIONS: Adults and older children performed both standardized static positions and functional activities. Younger children performed only a functional activity protocol. MAIN OUTCOME MEASURES: Joint angle measurements using the app were validated against a commercially validated two-dimensional goniometric software program. In addition, validity of the app was compared to a standard mechanical goniometer for the measurement of angles drawn on a white board. Intra- and interrater reliability were assessed through independent rescoring of videos. RESULTS: Correlations between joint angle estimates obtained from the app and goniometer software or a mechanical goniometer were positive and very strong (r>.900; P<.0001). The intraclass correlation coefficient (ICC) for repeated scoring from the app indicated excellent intra- and interrater reliability (ICC>.900). CONCLUSIONS: High correlations for repeated measures and comparison to gold standard angle measurement instruments suggest that the new app is a valid and reliable tool for assessing joint angles during functional activity. This tool may provide clinicians an inexpensive yet accurate method for quantification of movements and immediate feedback on range of motion during tasks in a natural environment.

Play with objects in children with arthrogryposis: Effects of intervention with the Playskin Lift™ exoskeletal garment.

Children with arthrogryposis multiplex congenita (AMC) often exhibit arm movement impairments that can negatively impact activities of daily living, such as reaching, object exploration, object play, and self-care. This study evaluated the effects of intervention involving the Playskin Lift™ (Playskin) exoskeletal garment on arm function during object play for children with AMC. Seventeen children with AMC (5 males; 6-35 months at the beginning of the study) were tested in their homes biweekly with and without the Playskin throughout a 1-month Baseline, 4-month Intervention, and 1-month Post-Intervention. Within sessions (assistive effects), children contacted and manipulated objects more while wearing the Playskin; they also showed greater intensity, complexity, and variability of behaviors performed during free play, as well as increased play space and reduced number of compensatory arm and trunk flings to facilitate reaching. Across time (rehabilitative effects), children significantly improved their visual-manual coupling as well as their ability to lift objects from a surface and to manipulate objects using one hand; in addition, children exhibited greater multimodality, variability, and intensity of their play behaviors. Current results suggest the Playskin Lift™ may serve as an effective assistive and rehabilitative device to improve play for children with arm movement impairments.

Feasibility and Effectiveness of Intervention With the Playskin Lift Exoskeletal Garment for Infants at Risk.

BACKGROUND: Infants born preterm and/or with brain injury often exhibit delays in the development of reaching and object exploration, increasing their risk of associated delays in cognitive development. OBJECTIVE: The objective of this study was to longitudinally evaluate feasibility of use of the novel Playskin Lift exoskeletal garment (Playskin; developed and trademarked by Dr. Lobo's Super Suits FUNctional Fashion and Wearable Technology Program at the University of Delaware, Newark, DE, USA), the assistive and rehabilitative effects of intervention with the garment on reaching and object exploration ability, and to relate changes in reaching and object exploration to changes in cognition during intervention for infants at risk for developmental delays. DESIGN: A multiple baseline single-case design with 1- to 2-month Baseline, 4-month Intervention, and 1-month Postintervention phases was implemented. METHODS: Ten infants born preterm and/or with brain injury, mean [SD] age 2.2 [1.3] months at the beginning of the study, were assessed biweekly throughout the study both with and without the Playskin Lift. Assessments included a Reaching Assessment and the cognitive subscale of the Bayley Scales of Infant and Toddler Development. Reaching and object exploration behaviors were coded from videos of the Reaching Assessment. Results were analyzed using multilevel modeling in SAS. RESULTS: The Playskin Lift improved infants' reaching ability, hand orientation for grasp and object exploration, and multimodal object exploration when worn within sessions, especially during the Intervention phase. The garment also improved independent reaching and object exploration across time during the Intervention phase, with retention of gains in the Postintervention phase. Improvement in reaching ability was positively related to changes in cognitive outcomes during the Intervention phase. LIMITATIONS: Limitations included modest sample size and the potential confounds of development and experience with time. CONCLUSIONS: The Playskin Lift can serve as a feasible, effective, and accessible assistive and rehabilitative device to advance reaching, object exploration, and cognition for infants at risk for future delays.

Development of self-feeding behavior in children with typical development and those with arm movement impairments.

Self-feeding is a critical self-care skill that unites motor abilities (e.g., grasping and transporting utensils/food to the mouth) and cognitive abilities (e.g., using a spoon as a tool). This cross-sectional study assessed self-feeding behavior in a sample of 38 children with typical development (TD) and compared it between 18 of those children and 18 age- and sex-matched peers with arm movement impairments (MI). Children were assessed with a bowl of cereal and two spoons presented in four different orientations. Results suggested that children with MI were less successful than their TD peers in both motor aspects (e.g., grasp and transport of food and utensils) and cognitive aspects (correct grasp across spoon orientations) of self-feeding. Novel findings highlight: (a) interesting differences in visual attention between children with TD or MI; (b) the role of hand-preference in the correct grasping of the spoon(s) and effective self-feeding; (c) the positive relation between motor and cognitive aspects of self-feeding; and (d) that greater variability of self-feeding behavior relates to improved performance of cognitive aspects of the task. These results identify challenging components of self-feeding for children with MI that should be targeted by early interventions and assistive technologies aimed at increasing self-feeding independence.

Means-end problem solving in infancy: Development, emergence of intentionality, and transfer of knowledge.

Behaviors and performance of 23 typically developing infants were assessed longitudinally at 6, 9, 12, 18, and 24 months in two means-end tasks: pulling a towel or rotating a turntable to obtain a supported object. With age, infants performed more goal-directed behaviors, leading to increased problem-solving success. Intentionality emerged earlier in the towel task than in the turntable task (6.9 vs. 10.8 months). Potential knowledge transfer between the tasks was first observed at 9 months. This study provides insight into the development of means-end learning, the emergence of intentionality, and potential transfer of knowledge in tasks involving a similar concept (support) but requiring different modes of action for success (pulling vs. rotating).

Evolution and development of handedness: An Evo-Devo approach.

Hand preference is a sensorimotor skill whose development both reflects and promotes the development of hemispheric lateralization for manual and cognitive functions. Extensive comparative, crosscultural, and paleoanthropological evidence demonstrates the prevalence of limb lateralized preferences across vertebrate species and the prevalence of right-handedness within hominid evolution. Many reviews of the evolution and development of human handedness have proposed adaptive explanations for its evolution. However, during the last 3 decades a new approach to understanding evolution (the Extended Evolutionary Synthesis-EES) provided a persuasive alternative to the conventional (Neo-Darwinian Synthetic Theory-ST) evolutionary and developmental accounts. EES combines modern evolutionary and developmental research (Evo-Devo) in ways that alter understanding of natural selection, adaptation, and the role of genes in development and evolution. These changes make obsolete all past accounts of the evolution and development of lateralization and handedness because EES/Evo-Devo requires new study designs. The developmental trajectories of any structural or functional trait must be specified so that it may be related to variations in the developmental trajectories of other traits. First, we describe how the EES/Evo-Devo differs from the conventional ST, particularly for understanding of how traits develop. Then, we apply Evo-Devo to the study of handedness development in infancy and its relation to the development of other cognitive functions. Finally, we argue that identifying the development of atypical traits would benefit from knowledge of the range of individual differences in typical developmental trajectories of hand-use preference and their relation to variations in the developmental trajectories of cognitive functions.

Sitting Together And Reaching To Play (START-Play): Protocol for a Multisite Randomized Controlled Efficacy Trial on Intervention for Infants With Neuromotor Disorders.

Background: There is limited research examining the efficacy of early physical therapy on infants with neuromotor dysfunction. In addition, most early motor interventions have not been directly linked to learning, despite the clear association between motor activity and cognition during infancy. Objective: The aim of this project is to evaluate the efficacy of Sitting Together And Reaching To Play (START-Play), an intervention designed to target sitting, reaching, and motor-based problem solving to advance global development in infants with motor delays or neuromotor dysfunction. Design: This study is a longitudinal multisite randomized controlled trial. Infants in the START-Play group are compared to infants receiving usual care in early intervention (EI). Setting: The research takes place in homes in Pennsylvania, Delaware, Washington, and Virginia. Participants: There will be 140 infants with neuromotor dysfunction participating, beginning between 7 to 16 months of age. Infants will have motor delays and emerging sitting skill. Intervention: START-Play provides individualized twice-weekly home intervention for 12 weeks with families to enhance cognition through sitting, reaching, and problem-solving activities for infants. Ten interventionists provide the intervention, with each child assigned 1 therapist. Measurements: The primary outcome measure is the Bayley III Scales of Infant Development. Secondary measures include change in the Early Problem Solving Indicator, change in the Gross Motor Function Measure, and change in the type and duration of toy contacts during reaching. Additional measures include sitting posture control and parent-child interaction. Limitations: Limitations include variability in usual EI care and the lack of blinding for interventionists and families. Conclusions: This study describes usual care in EI across 4 US regions and compares outcomes of the START-Play intervention to usual care.

Prematurity may negatively impact means-end problem solving across the first two years of life.

Preterm infants are at risk for delays in motor, perceptual, and cognitive development. While research has shown preterm infants may exhibit learning delays in the first months of life, these delays are commonly under-diagnosed. The purpose of this study was to longitudinally evaluate behavioral performance and learning in two means-end problem-solving tasks for 30 infants born preterm (PT) and 23 born full-term (FT). Infants were assessed at 6, 9, 12, 18, and 24 months-old in tasks that required towel pulling or turntable rotation to obtain a distant object. PT infants performed more non-goal-directed and less goal-directed behavior than FT infants throughout the study, resulting in a lower success rate among PT infants. PT infants showed delayed emergence of intentionality (prevalence of goal-directed behaviors) compared to FT infants in both tasks. Amount and variability of behavioral performance significantly correlated with task success differentially across age. The learning differences documented between PT and FT infants suggest means-end problem-solving tasks may be useful for the early detection of learning delays. The identification of behaviors associated with learning and success across age may be used to guide interventions aimed at advancing early learning for infants at risk.