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.

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 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.

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.

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.

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).

Single-Case Design, Analysis, and Quality Assessment for Intervention Research.

BACKGROUND AND PURPOSE: The purpose of this article is to describe single-case studies and contrast them with case studies and randomized clinical trials. We highlight current research designs, analysis techniques, and quality appraisal tools relevant for single-case rehabilitation research. SUMMARY OF KEY POINTS: Single-case studies can provide a viable alternative to large group studies such as randomized clinical trials. Single-case studies involve repeated measures and manipulation of an independent variable. They can be designed to have strong internal validity for assessing causal relationships between interventions and outcomes, as well as external validity for generalizability of results, particularly when the study designs incorporate replication, randomization, and multiple participants. Single-case studies should not be confused with case studies/series (ie, case reports), which are reports of clinical management of a patient or a small series of patients. RECOMMENDATIONS FOR CLINICAL PRACTICE: When rigorously designed, single-case studies can be particularly useful experimental designs in a variety of situations, such as when research resources are limited, studied conditions have low incidences, or when examining effects of novel or expensive interventions. Readers will be directed to examples from the published literature in which these techniques have been discussed, evaluated for quality, and implemented.

Development of role-differentiated bimanual manipulation in infancy: Part 2. Hand preferences for object acquisition and RDBM--continuity or discontinuity?

This second paper in a series of three investigated the development of hand preference for role-differentiated bimanual manipulation (RDBM) relative to the infant's hand preference for object acquisition and to the infant's hand-use for acquiring the objects used to assess RDBM. The same 90 infants (30 with a right preference, 30 with a left preference, and 30 with no preference to acquire objects) from the first paper were tested from 9 to 14 months for hand preference for acquiring those objects used to assess RDBM and for a hand preference for RDBM. Multilevel analysis revealed that infants with a hand preference for acquiring objects decreased in their use of the preferred hand for object acquisition during the 11 to 14 month interval, which coincided with the development of a hand preference for RDBM. These results are discussed in relation to the cascade theory of hand preference development.

Development of role-differentiated bimanual manipulation in infancy: Part 3. Its relation to the development of bimanual object acquisition and bimanual non-differentiated manipulation.

This third paper in a series of three related developmental trajectories of bimanual object acquisition and non-differentiated bimanual manipulation (NDBM) to patterns of role-differentiated bimanual manipulation (RDBM) development to help identify the sequence of events that might predict (and potentially facilitate) the development of RDBM skill. Ninety infants were tested monthly from 6 to 14 months of age for object acquisition, and from 9 to 14 months for NDBM and RDBM. The results did not support the hypothesis proposing that the onset of RDBM would require decoupling of the hands in unimanual acquisition, but supported the prediction that coupling of the hands in bimanual acquisition would predict increasing expertise in the RDBM skill. The relation between the bimanual object acquisition and RDBM was found to be mediated by NDBM, which prompts the hypothesis that bimanual acquisition of objects facilitates the development of NDBM, which, in its turn, facilitates the development of the RDBM skill.

Development of role-differentiated bimanual manipulation in infancy: Part 1. The emergence of the skill.

This is the first paper in a series of three discussing different aspects of the development of role-differentiated bimanual manipulation (RDBM-two hands performing different but complementary actions on an object). Emergence of RDBM is an important shift in the development of infant manual skills. Trajectories of monthly changes in the number of RDBMs and RDBM hand preference were explored in a sample of 90 (57 males) normally developing infants (30 with a right preference for acquiring objects, 30 with a left preference, 30 with no preference) during the 9-14 month period. Multilevel analysis revealed that infants performed more RDBMs with age, with similar patterns of change in all hand preference groups. A hand-use preference for RDBM became more prominent with age with most right-preferring infants and those without a preference for object acquisition developing right-hand preference for RDBM. Left-preferring infants exhibited more heterogeneity in their hand-use for RDBM.

Feasibility and Effectiveness of a Novel Exoskeleton for an Infant With Arm Movement Impairments.

PURPOSE: To determine whether a novel exoskeletal device (Pediatric-Wilmington Robotic Exoskeleton [P-WREX]) is feasible and effective for intervention to improve reaching and object interaction for an infant with arm movement impairments. METHODS: An 8-month old infant with arthrogryposis was followed up every 2 weeks during a 1-month baseline, 3-month intervention, and 1-month postintervention. At each visit, reaching and looking behaviors were assessed. RESULTS: Within sessions, the infant spent more time contacting objects across a larger space, contacting objects with both hands, and looking at objects when wearing the P-WREX. Throughout intervention, the infant increased time contacting objects both with and without the device and increased bilateral active shoulder flexion. CONCLUSIONS: (1) It may be feasible for families to use exoskeletons for daily intervention, (2) exoskeletons facilitate immediate improvements in function for infants with impaired upper extremity mobility, and (3) interventions using exoskeletons can improve independent upper extremity function across time.

Postural influences on the development of infant lateralized and symmetric hand-use.

Within-individual variability is such an apparent characteristic of infant handedness that handedness is believed to consolidate only in childhood. Research showed that manifest handedness is influenced by emerging postural skills (sitting, crawling, and walking). In this investigation, it was proposed that symmetric hand-use (tendency to acquire objects bimanually), rather than lateralized hand-use (the use of one hand more than the other), may be influenced by postural changes. Trajectories of lateralized and symmetric hand-use for object acquisition were examined in 275 infants tested monthly from 6 to 14 months. Multilevel modeling revealed that change in lateralized hand-use is unrelated to developmental transitions in infant posture, whereas the trajectory of symmetric hand-use changes significantly with the development of postural skills.

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).

How the development of handedness could contribute to the development of language.

We propose a developmental process which may link the development of handedness with the development of hemispheric specialization for speech processing. Using Arbib's proposed sequence of sensorimotor development of manual skills and gestures (that he considers to be the basis of speech gestures and proto-language), we show how the development of hand-use preferences in proto-reaching skills concatenate into object acquisition skills and eventually into role-differentiated bimanual manipulation skills (that reflect interhemispheric communication and coordination). These latter sensorimotor skills might facilitate the development of speech processing via their influence on the development of tool-using and object management abilities.

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.

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).