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).

Sitting Capacity and Performance in Infants with Typical Development and Infants with Motor Delay.

AIMS: Infants with neuromotor disorders demonstrate delays in sitting skills (decreased capacity) and are less likely to maintain independent sitting during play than their peers with typical development (decreased performance). This study aimed to quantify developmental trajectories of sitting capacity and sitting performance in infants with typical development and infants with significant motor delay and to assess whether the relationship between capacity and performance differs between the groups. METHODS: Typically developing infants (n = 35) and infants with significant motor delay (n = 31) were assessed longitudinally over a year following early sitting readiness. The Gross Motor Function Measure (GMFM) Sitting Dimension was used to assess sitting capacity, and a 5-min free play observation was used to assess sitting performance. RESULTS: Both capacity and performance increased at a faster rate initially, with more deceleration across time, in infants with typical development compared to infants with motor delay. At lower GMFM scores, changes in GMFM sitting were associated with larger changes in independent sitting for infants with typical development, and the association between GMFM sitting and independent sitting varied more across GMFM scores for typically developing infants. CONCLUSIONS: Intervention and assessment for infants with motor delay should target both sitting capacity and sitting performance.

White privilege and teacher perceptions of teacher-child relationship quality.

In this study, we investigated differences in teachers' perceptions of the teacher-child relationship from kindergarten through second grade as a function of child race and gender from the perspective of critical race theory and the cultural synchrony hypothesis. Given the extensive evidence of White privilege and anti-Black racism in the US education system, we expected that teachers, particularly White teachers, would perceive their relationships with White children more positively than with Black children. Controlling for family SES and child gender, results supported this hypothesis. Black boys had the highest risk of being perceived by teachers as having poor relationships with teachers in kindergarten (highest conflict and lowest closeness) and White girls had the lowest risk. In addition, teachers perceived relationships with Black boys as increasing in conflict across first and second grades at higher rates than with White and female children. These findings remained after examining teacher-child racial match as a moderator. Our results indicate that racism and sexism work together to explain the perceptions teachers have of children in the early elementary grades. Implications for training teachers and school psychologists on anti-racism and cultural competency are discussed.

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.

Opportunities for learning and social interaction in infant sitting: Effects of sitting support, sitting skill, and gross motor delay.

The development of independent sitting changes everyday opportunities for learning and has cascading effects on cognitive and language development. Prior to independent sitting, infants experience the sitting position with physical support from caregivers. Why does supported sitting not provide the same input for learning that is experienced in independent sitting? This question is especially relevant for infants with gross motor delay, who require support in sitting for many months after typically developing infants sit independently. We observed infants with typical development (n = 34, ages 4-7 months) and infants with gross motor delay (n = 128, ages 7-16 months) in early stages of sitting development, and their caregivers, in a dyadic play observation. We predicted that infants who required caregiver support for sitting would spend more time facing away from the caregiver and less time contacting objects than infants who could sit independently. We also predicted that caregivers of supported sitters would spend less time contacting objects because their hands would be full supporting their infants. Our first two hypotheses were confirmed; however, caregivers spent surprisingly little time using both hands to provide support, and caregivers of supported sitters spent more time contacting objects than caregivers of independent sitters. Similar patterns were seen in the group of typically developing infants and the infants with motor delay. Our findings suggest that independent sitting and supported sitting provide qualitatively distinct experiences with different implications for social interaction and learning opportunities. HIGHLIGHTS: During seated free play, supported sitters spent more time facing away from their caregivers and less time handling objects than independent sitters. Caregivers who spent more time supporting infants with both hands spent less time handling objects; however, caregivers mostly supported infants with one or no hands. A continuous measure of sitting skill did not uniquely contribute to these behaviors beyond the effect of binary sitting support (supported vs. independent sitter). The pattern of results was similar for typically developing infants and infants with gross motor delay, despite differences in age.

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.

A Regression Discontinuity Design Framework for Controlling Selection Bias in Evaluations of Differential Item Functioning.

Differential item functioning (DIF) is often used to examine validity evidence of alternate form test accommodations. Unfortunately, traditional approaches for evaluating DIF are prone to selection bias. This article proposes a novel DIF framework that capitalizes on regression discontinuity design analysis to control for selection bias. A simulation study was performed to compare the new framework with traditional logistic regression, with respect to Type I error and power rates of the uniform DIF test statistics and bias and root mean square error of the corresponding effect size estimators. The new framework better controlled the Type I error rate and demonstrated minimal bias but suffered from low power and lack of precision. Implications for practice are discussed.

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.

The SIT-PT Trial Protocol: A Dose-Matched Randomized Clinical Trial Comparing 2 Physical Therapist Interventions for Infants and Toddlers With Cerebral Palsy.

OBJECTIVE: Although early intervention for infants at risk for cerebral palsy is routinely recommended, the content of intervention is poorly described, varies widely, and has mixed supporting evidence. The purpose of this study was to compare efficacy of 2 interventions grounded in differing domains of the International Classification of Functioning, Disability and Health on developmental outcomes of infants with or at high risk of cerebral palsy. METHODS: Infants who meet inclusion criteria will be randomized into either Sitting Together and Reaching To Play or Movement, Orientation, Repetition, Exercise Physical Therapy groups. Both groups will receive intervention twice weekly for 3 months and follow-up at 3, 6, 9, and 12 months from baseline. The primary objectives compare changes over time and between groups in sitting, gross motor, and cognitive development. The setting is the infant's home unless the caregiver requests otherwise. One hundred and fifty infants between 8 and 24 months of age will be enrolled in 3 geographically, racially, and ethnically diverse sites: Los Angeles, California; Omaha, Nebraska; and Seattle, Washington. Enrolled infants will demonstrate motor delays, emerging sitting skills, and signs of neurologic impairment. Sitting Together and Reaching To Play targets activities including sitting, reaching, and motor-based problem solving to improve global development. In contrast, Movement, Orientation, Repetition, Exercise Physical Therapy focuses on strengthening and musculoskeletal alignment while encouraging repeated movement practice. Outcome measures include the Gross Motor Function Measure, Bayley Scales of Infant Development-IV, Assessment of Problem Solving in Play, and a Parent Child Interaction assessment. Enrolled children will maintain usual intervention services due to ethical concerns with intervention withdrawal. IMPACT: This will be the first study, to our knowledge, comparing efficacy of early physical therapy with dose-matched interventions and well-defined key principles. The outcomes will inform selection of key principle of intervention in this population.

Effect of the START-Play Physical Therapy Intervention on Cognitive Skills Depends on Caregiver-Provided Learning Opportunities.

AIMS: This study evaluated whether caregiver-provided learning opportunities moderated the effect of START-Play physical therapy intervention on the cognitive skills of young children with neuromotor delays, and whether START-Play impacted caregiver-provided learning opportunities over time. METHODS: One hundred and twelve children with neuromotor delays (7-16 months) participated in a multisite randomized clinical trial evaluating the efficacy of START-Play. Children were assessed at baseline and 3 (post intervention), 6, and 12 months post baseline. Cognition was scored from the Bayley Scales of Infant & Toddler Development, Third Edition, cognitive scale. The proportion of time caregivers spent providing learning opportunities was coded from a 5-minute caregiver-child free play interaction. RESULTS: Baseline caregiver-provided learning opportunities moderated the 3- and 12-month effects of START-Play on cognition. Cognitive gains due to START-Play were more pronounced for children whose caregivers provided more learning opportunities. START-Play did not impact caregiver-provided learning opportunities over time. CONCLUSIONS: START-Play may have a lasting effect on children's cognition, but this effect is contingent on caregivers providing their child with ample opportunities to practice cognitive skills. Strategies for improving caregivers' uptake and transfer of START-Play principles to their daily routines should be evaluated. TRIAL REGISTRATION: ClinicalTrials.gov NCT02593825.

Infant posture and caregiver-provided cognitive opportunities in typically developing infants and infants with motor delay.

Infants' developing motor skills-including mastery of new postures such as sitting and standing-affect opportunities for learning that facilitate cognitive development. But how infant posture affects caregiver behavior is largely unexplored. Moreover, we know little about effects of posture on learning opportunities in infants with motor delay. This study asked how infants with typical development and infants with significant motor delay use various postures during play, and whether posture is related in real time to caregiver-provided cognitive learning opportunities. Infants were videotaped five times over the course of a year in a free play session with a caregiver, starting when they demonstrated initial sitting skills. Posture and cognitive opportunities were coded moment-by-moment to assess duration and temporal overlap. We found that infants with typical development and infants with motor delay displayed similar use of postures initially, but infants with typical development demonstrated more mature postures over time. We also found that for both groups of infants, caregivers were most likely to provide cognitive opportunities when infants were sitting independently, and least likely when infants were supine. Our findings highlight the importance of upright sitting in typical and atypical infant development and suggest potential areas of intervention for infants with motor delay.

Validation of the short version of the dimensional inventory for child development assessment

Abstract Objectives: There is a critical need to monitor the development of children around the world, and in Brazil, this need is substantial since there is a paucity of assessment tools. This study aimed to describe the design and provide evidence of reliability and validity for the short version of the Dimensional Inventory for Child Development Assessment (IDADI-short). Methods: A sample of 1,865 biological mothers of children aged 4-72 months (M = 34.8, SD = 20.20) completed the IDADI to assess Cognitive, socio-emotional, Expressive, and Receptive Language and Communication, Fine and Gross Motor, and Adaptive Behavior development. The psychometric properties of a total of 118 subscales of IDADI were obtained and the IDADI-short age-specific scores were correlated with the original inventory, and criteria variables such as neurodevelopment diagnosis, socioeconomic status, and sex. Results: Item Response Theory analysis, Cronbach's Alpha, and McDonald's Omega indicated excellent internal consistency and optimal participant discrimination after minor alterations. IDADI-short scores were strongly associated with the original inventory, with high sensibility and specificity precision for developmental delays. Significant associations with relevant criteria variables were also observed. Conclusion: Findings support the use of IDADI-short as a parental measure of young children's development.

Early motor skills predict the developmental trajectory of problem solving in young children with motor delays.

INTRODUCTION: The purpose of this study was to quantify the relationship between early motor skills, such as sitting, and the development of problem-solving skills in children with motor delays. METHODS: Motor (Gross Motor Function Measure) and problem-solving (Assessment of Problem-Solving in Play) skills of 134 children 7-16 months adjusted age at baseline with motor delay were assessed up to 5 times over 12 months. Participants were divided into two groups: mild and significant motor delay. RESULTS: Motor and problem-solving scores had large (r's = 0.53-0.67) and statistically significant (p's > .01) correlations at all visits. Baseline motor skills predicted baseline and change in problem solving over time. The associations between motor and problem-solving skills were moderated by level of motor delay, with children with significant motor delay generally having stronger associations compared to those with mild motor delay. CONCLUSIONS: These findings suggest that overall baseline motor skills are predictive of current and future development of problem-solving skills and that children with significant motor delay have a stronger and more stable association between motor and problem-solving skills over time. This highlights that children with motor delays are at risk for secondary delays in problem solving, and this risk increases as degree of motor delay increases.

Targeted Physical Therapy Combined with Spasticity Management Changes Motor Development Trajectory for a 2-Year-Old with Cerebral Palsy.

Therapies for children with cerebral palsy (CP) often fail to address essential components of early rehabilitation: intensity, child initiation, and an embodied approach. Sitting Together And Reaching To Play (START-Play) addresses these issues while incorporating intensive family involvement to maximize therapeutic dosage. While START-Play was developed and tested on children aged 7-16 months with motor delays, the theoretical construct can be applied to intervention in children of broader ages and skills levels. This study quantifies the impact of a broader START-Play intervention combined with Botulinum toxin-A (BoNT-A) and phenol on the developmental trajectory of a 24 month-old child with bilateral spastic CP. In this AB +1 study, A consisted of multiple baseline assessments with the Gross Motor Function Measure-66 and the Assessment of Problem Solving in Play. The research participant demonstrated a stable baseline during A and changes in response to the combination of BoNT-A/phenol and 12 START-Play sessions during B, surpassing the minimal clinically important difference on the Gross Motor Function Measure-66. The follow-up data point (+1) was completed after a second round of BoNT-A/phenol injections. While the findings suggest the participant improved his gross motor skills with BoNT-A/phenol and START-Play, further research is needed to generalize these findings.

Validation of the short version of the dimensional inventory for child development assessment.

OBJECTIVES: There is a critical need to monitor the development of children around the world, and in Brazil, this need is substantial since there is a paucity of assessment tools. This study aimed to describe the design and provide evidence of reliability and validity for the short version of the Dimensional Inventory for Child Development Assessment (IDADI-short). METHODS: A sample of 1,865 biological mothers of children aged 4-72 months (M = 34.8, SD = 20.20) completed the IDADI to assess Cognitive, socio-emotional, Expressive, and Receptive Language and Communication, Fine and Gross Motor, and Adaptive Behavior development. The psychometric properties of a total of 118 subscales of IDADI were obtained and the IDADI-short age-specific scores were correlated with the original inventory, and criteria variables such as neurodevelopment diagnosis, socioeconomic status, and sex. RESULTS: Item Response Theory analysis, Cronbach's Alpha, and McDonald's Omega indicated excellent internal consistency and optimal participant discrimination after minor alterations. IDADI-short scores were strongly associated with the original inventory, with high sensibility and specificity precision for developmental delays. Significant associations with relevant criteria variables were also observed. CONCLUSION: Findings support the use of IDADI-short as a parental measure of young children's development.

Measuring Early Problem-Solving in Young Children with Motor Delays: A Validation Study.

AIM: There is a lack of evidence-based tools for measuring problem-solving in young children with motor delays. The purpose of this study was to evaluate the construct validity and responsiveness of the Assessment of Problem-Solving in Play. METHODS: 125 young children (10.72, SD 2.62 months) with mild, moderate, and severe motor delays were assessed with the Bayley Scales of Infant and Toddler Development, Third Edition Cognitive Scale and the Assessment of Problem-Solving in Play up to 4 times over 12 months. The baseline and change over time assessment scores were compared. RESULTS: The Assessment of Problem-Solving in Play was strongly, positively correlated with the Bayley Scales of Infant and Toddler Development, Third Edition Cognitive Scale raw scores at baseline (r=.83, p<.001) and for changes in scores across time (r=.64, p<.001). On average, participants demonstrated positive change in problem-solving scores across time. Participants with severe motor delay scored lower at baseline and changed less as compared to other participants. CONCLUSIONS: Results provide evidence for the construct validity and responsiveness of the Assessment of Problem-Solving in Play scores in quantifying problem-solving in young children with motor delays 7-27 months of age.

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.

Developing a fidelity measure of early intervention programs for children with neuromotor disorders.

AIM: To describe the development of an intervention-specific fidelity measure and its utilization and to determine whether the newly developed Sitting Together and Reaching to Play (START-Play) intervention was implemented as intended. Also, to quantify differences between START-Play and usual early intervention (uEI) services. METHOD: A fidelity measure for the START-Play intervention was developed for children with neuromotor disorders by: (1) identifying key intervention components, (2) establishing a measurement coding system, and (3) testing the reliability of instrument scores. After establishing acceptable interrater reliability, 103 intervention videos from the START-Play randomized controlled trial were coded and compared between the START-Play and uEI groups to measure five dimensions of START-Play fidelity, including adherence, dosage, quality of intervention, participant responsiveness, and program differentiation. RESULTS: Fifteen fidelity variables out of 17 had good to excellent interrater reliability evidence with intraclass correlation coefficients (ICCs) ranging from 0.77 to 0.95. The START-Play therapists met the criteria for acceptable fidelity of the intervention (rates of START-Play key component use ≥0.8; quality ratings ≥3 [on a scale of 1-4]). The START-Play and uEI groups differed significantly in rates of START-Play key component use and quality ratings. INTERPRETATION: The START-Play fidelity measure successfully quantified key components of the START-Play intervention, serving to differentiate START-Play from uEI.

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.

A Physical Therapy Intervention to Advance Cognitive and Motor Skills: A Single Subject Study of a Young Child With Cerebral Palsy.

BACKGROUND: Physical therapy interventions for children with severe motor impairments do not address the relationship between motor and cognitive development. PURPOSE: Evaluate the potential of a physical therapy intervention focusing on enhancing cognitive and motor outcomes in a child with severe motor impairments. DESIGN: AB phase design without reversal. METHODS: One child participated in 8 assessments from 4 to 29 months of age. The START-Play intervention was provided for 3 months following 4 baseline assessments over 12 months. Total Gross Motor Function Measure (GMFM), Sitting, Reaching, and Problem Solving assessments were completed. Visual inspection, 2 standard deviation (SD) Band Method, and percent of nonoverlapping data methods evaluated change. RESULTS: This child had improved GMFM total and sitting scores, increased frequency of toys contacts, and increased rate of problem-solving behaviors following intervention. CONCLUSION: START-Play shows promise for children with severe motor impairments. Additional research is needed to evaluate efficacy.