Developmental Theory Final

Micropreemie

<28 weeks gestational age

Prematurity

28-37 weeks gestational age

Full term

37-42 weeks gestational age

Post term

>42 week gestational age

Chronological age vs corrected age

Chronological age = the baby’s actual age from their birth date.

Corrected age = chronological age minus the number of weeks (or months) the baby was born early.

This adjustment is important because development is expected to line up more closely with corrected age until about 2 years old, after which most preterm children “catch up.”

NICU OT’s role

• Developmental assessments

• Positioning

• Feeding assessments

• Splinting

• Evidence-based Interventions

• Caregiver education

Developmental assessment goal

Optimize infant positioning and development throughout hospitalization by supporting nursing staff and educating parents/caregivers

Neuroprotection

mechanisms and strategies to protect against neuronal injury or the degeneration of the central nervous system (CNS) after an acute event/ disorder.

Goal with neuroprotection

limit damage from the acute injury and provide care to maintain the highest possible integrity of cellular functions and interactions.

What does neuroprotection look like in the NICU?

Maintains constant temp → isolette for temp

Supports flexed and midline positioning → swaddling or towel rolls

Limited sensory input → cover for dim lighting

Allows symmetrical growth → gel pillow for head shape

Supports calming behavior → quiet hours for rest

Preemie communication stress cues

• Stop sign - fingers are extended or splayed, often with arm extended

• Furrowed brow - concerned or worried look creating lines/wrinkles on forehead

• Arms & leg extension - arms and/or legs are held in position of extension

• Gaze aversion - moves eyes away from caregiver/situation

Supportive responses to stress — Grasping Finger

Provide a finger for your baby to grasp or hold. You may notice your baby comforting themselves by grasping onto their own hands or even equipment in the bed

Supportive responses to stress — Hands to face/mouth

Help your baby by moving their hands to their face or near their mouth.

Supportive responses to stress — Hand hug

Help your baby by gently gathering their arms and/or legs and tucking them closer to their body. Hold with gentle pressure with their body relaxes. This is not only calming but also helps your baby develop normal movement patterns

Supportive responses to stress — Skin-to-skin holding

Hold your diapered baby skin-to-skin on your chest. This helps with bonding, growth, attachment, immune system development, brain development, temperature stability, your milk production and more

Supportive responses to stress — Timeout

Your baby may benefit from a brief break in care if stress signs continue despite support

1. Healing environment

2. Positioning & handling

3. Safeguarding sleep

4. Minimize stress and pain

5. Protect skin

6. Optimizing nutrition

7. Partnering with families

Correcting the order of sensory input

• tactile, vestibular, chemosensory, auditory, visual

Peri oral stimulation - cheek

Using index finger and thumb, stroke both cheeks simultaneously starting away from the mouth and moving towards the mouth

Peri oral stimulation - lip

Using index finger, make full contact with skin above upper and below lower lip and move right to left without losing contact with skin.

Feeding strategies in the NICU

• Oral stimulation

• Parent education

• Nursing education

• Feeding evaluation

• Assessment - behavioral state, regulation, autonomic stability, overall muscle tone, oral structures, oral reflexes, NNS via gloved finger and/or pacifier, small volume PO

Cerebral palsy

a physical disability affecting movement and posture, caused by brain injury before, during, or shortly after birth.

Spastic CP (80%)

stiff muscles; includes diplegia, hemiplegia, quadriplegia affects hands, arm, leg movement, making sitting and walking difficult

Functional impact: difficulty with coordinated movements, walking, grasping objects, transferring, writing, and maintaining posture

Dyskinetic CP & functional performance affected

Problems with controlled movements of hands, arms, feet, and leg

Functional impact: Trouble with controlled hand use, feeding, speech, maintaining stable posture

Ataxic CP & functional performance affected

problems with balance and coordination

Functional impact: Difficulty with fine motor skills like handwriting, cutting, using utensils, and precise hand-eye coordination tasks

Mixed CP & functional performance affected

combination of types, most commonly spastic-dyskinetic

Fine motor/handwriting supports for kids with CP

• Adaptive pencils or grips

• Weighted utensils or writing tools

• Voice to text technology

• Alternative keyboards or switches

Seating and posture supports for kids with CP

• Adaptive chairs or classroom seating with trunk support

• Wedges or cushions

• Adjustable desks or standing desks

• Footrests for stability

Mobility and positioning supports for kids with CP

• Walkers, gait trainers, or wheelchairs

• Rifton or adaptive seating systems

• Standing frame for participation and posture

Self-care and classroom independence supports for kids with CP

• Adaptive scissors

• Velcro fasteners on clothing or school materials

• Built up handles for eating or hygiene tools

• Non-slip mats or dycem

• Adaptive cups, plates, and utensils

Visual fixation

• Fixing on a stationary object.

• Required for other oculomotor movements (i.e. scanning or tracking)Think of it as the visual system’s foundation for “mobility on stability”

Visual pursuit

Tracking - eyes and head move together or eyes move independent of the head

Saccades

Rapid change in fixation between two or more given points

Accomodation

Ability to compensate for a blurred image

Binocular fusion

Ability to combine the images of the 2 eyes

Eye teaming

Controlling how we use and aim our eyes together is an important skill that keeps us from seeing double

Convergence and divergence

Ability of both eyes to turn inward and outward

Convergence insufficiency

• The eyes don’t work well together at near distances

• The eye tend to drift outward when doing something up close; reading, computer work, homework, etc.

How do individuals adapt to convergence insufficiency?

Most people suppress an eye— causing poor depth perception, ball skills, clumsiness, head tilt and poor posture during seated tasks

Visual memory

Integration of visual information and previous experiences

Visual discrimination

• Recognition

• Matching - to note similarities in visual stimuli

• Categorization - to note similarities and differences

• Object vision - identifies color, texture, shape and size

Form constancy

recognition of forms and objects as the same despite changes in orientation and detail (print versus cursive)

Visual closure

identification of forms from incomplete presentations (find a pencil in the desk that is partially covered)

Figure-ground

differentiate background from foreground (find a toy in a toy box)

Signs of focusing problems

• Child complains of blurred vision

• Eyestrain

• Watery or burning eyes

• Tired at the end of the school day

• Hold things very close

Signs of tracking problems

• Loses place often

• Skips lines and words often

• Difficulty watching moving items

• Slow copying

• Poor ball skills

• Short attention span

• Complains letters jump around when reading

Signs of visual memory and sequential memory problems

• Difficulty recalling where items are

• Takes a long time to copy words

• Seems to know material but tests poorly

• Poor spelling

• Frequent letter omissions

• Difficulty with recalling sequencing events or steps to ADLs

• Difficulty following directions

• Inconsistent on ADLs

Trouble with form constancy

• Trouble recognizing different fonts/styles of writing

• Trouble moving from print to cursive

• Difficulty identify letter and number reversals

• Unable to identify items when presented differently (whole fruit vs cut up fruit)

Trouble with spatial relations

• Trouble learning left from right

• Reverses letters and numbers frequently

• Difficulty with directionality terms

• Poor organizational skills

Trouble with figure ground

• Trouble locating item in busy background

• Difficulty locating toy in toy box

• Appears disorganized

• Becomes visually overwhelmed easily

• Skips line frequently

• Difficulty finding place on page

• Overlooks details

Trouble with visual closure

• Trouble finding items in pantry that are partially covered

• Poor sight word recognition

• Trouble with jigsaw puzzles

• Difficulty with games that require guessing an item based on close-up photo

What do school based OTs address?

• fine motor & visual skills - handwriting, cutting, drawing, using tools

• visual perceptual skills - tracking, spatial awareness, copying

• Environmental accessibility - classroom setup, seating,a and tool adaptations

• self help skills - dressing, feeding, hygiene at school

• sensory processing - attention, transitions, emotional control

• sensorimotor

• sensory integration skills

Referral to school based OT

A student may have difficulty with:

• Functional school related ADL skills

• functional handwriting skills

• sensory processing skills

• transitioning or attention skills

• social skills

What is an IEP?

• Legal binding document describing specific education needs of a child in a public school

• Developed following a very specific rules to ensure the eligible child receives a FAPE

• Once the team agrees it cannot be changed without following very specific steps

Referral/request submitted - evaluation must be completed no later than 60 days after request

504 plan — qualification to receive services

• Meets age requirement to attend public school in own district

• Has a disability that limits participation or access to school

• Does NOT meet eligibility criteria for services under Chapter 14

Reporting progress on IEP

• Quarterly reports - report cards, every 9 weeks (report progress on current goals & outcomes)

• Annual review - every year, report progress, new goals & outcomes

• Re-evaulation report - every 3 years, complete standardized testing, review findings, progress & reestablish qualification for services

Intervention choices

1. info-sharing (indirect)

2. Accomodations (indirect)

3. Collaborative consultation (indirect)

4. Direct intervention 

Autism spectrum disorder

A condition related to brain development that impacts how a person perceives and socialize with others, causing problems in social interaction and communication.

Also includes limited and repetitive patterns of behaviors

Sensory integration in child development

Emphasis in vestibular, tactile, and proprioceptive senses and their importance to development and occupations

Sensory integration definition

Unconscious brain function that organizes input from all senses, gives meaning to experiences by selecting what to focus on, and enables purposeful, adaptive responses. It provides the foundational skills needed for learning and social behavior.

Tactile defensiveness

Support a child with tactile defensiveness by providing consistent, varied tactile activities and using calming proprioceptive and vestibular input. Steady, deep pressure is more tolerable than light touch. These strategies can also improve fine motor skills, feeding, handwriting, and behavior.

Proprioception - an understanding of where my body is in space (joint position and movement). What is the clinical presentation of a child with impaired proprioception?

• may appear clumsy or uncoordinated

• Might trip/fall more often than other kids

• Might have difficulty with praxis and motor planning on playground equipment

How do we improve proprioceptive responses?

• Weights and “heavy work” are often used to provide increased input of body in space

• Practicing different body positions with feedback (animal walks, kid yoga with physical guidance or in front of a mirror)

• Breaking down complex motor sequences into achievable steps with repetition and incremental building (Motor Learning)

Vestibular system

• A primary organizer of sensory information

• Provides subconscious awareness of the body’s movements/position in space

• It modulates movements of the body and eyes relative to gravity, thus affecting posture and equilibrium

Semicircular canals

• Respond to angular or phasic movement and have a stimulating effect

  • Diagonal, circular, and unexpected movement patterns are alerting

Utricle and saccule 

• Respond to linear movement and static positioning and have a calming effect (such as rocking an infant)

  • Linear, horizontal, and rhythmic movement patterns are calming.

Low registration (high threshold + passive)

• Misses sensory cues

• May seem easygoing, quiet, or unaware of things (e.g., doesn’t notice name being called)

• Needs stronger or more intense input to engage

Sensation seeking (high threshold + active)

• Craves sensory input

• Loves movement, touching things, loud environments

• Actively seeks sensory experiences to stay regulated

Sensory Sensitivity (Low threshold + Passive)

• Notices everything quickly and easily

• Can be easily distracted, overwhelmed, or irritated

• Doesn’t try to avoid triggers but is affected by them

Sensation Avoiding (Low threshold + Active)

• Sensitive to sensory input and tries to control or escape it

• Prefers routines, quiet spaces, predictability

• Avoids sensory overload by limiting input

Calm/focus — vestibular movements

• Rhythmical rocking

• Swinging: linear

• Repetitive movements

• Predictable movements

Alert/stimulate — vestibular movements

• Spinning/rotary movement

• Swinging or moving in multiple, unpredictable patterns

• Inversion

Calm/focus — proprioception

• Pushing / Pulling / Carrying Heavy Objects

• Pushing Uphill

• Closed Chain Movements (hands / feet attached to ground)

• Weighted Vest, Lap / Neck Pad, Blanket, Blanket Roll Up

• Joint Compression

• Enclosed Space

• Kid Yoga

• Climbing (organized)

• Patterned, Slow Motion Songs: Clapping, rubbing hands

Alert/stimulate — proprioception

• Jumping and Bouncing: Unpredictable Patterns

• Crazy Animals

• Playgrounds: Climbing, jumping, crawling (unpredictable)

• Open Chain Movements: Bouncy Toys like Hippity Hop

• Stomping

• Scooter Boards

Alert/stimulate — tactile

• Cool Temperatures

• Light Touch

• Unpredictable Touch

• Vibration (child dependent)

• Sand Tracing Letters

• Shaving Cream (child dependent)

Calm/focus — visual

• Low Lighting

• Decreased Visual Stimuli

• Sunglasses

• Lava lamp / Slow moving visuals

• Aquarium

• Sensory Bottles

Alert/stimulate — visual

• Bright Light

• Flashing Light

• Blue Light – any electronic

• Contrasting bright colors

• Fast moving visuals

• Light up toys

• Seek and Finds/ Clutter

• Hanging objects

Calm/focus — auditory

• <50 beats per minute

• Instrumental music

• Metronome set to <50 bpm

• Drumming

• Rhythm

• Lower Frequencies (not Low, threatening)

• Nature sounds: Waves, water

• Melodic

• “Motherese”

• Pink Noise

Alert/stimulate — auditory

• 55-70 bpm for learning

• 70-100 bpm for energizing

• Metronome set about 70 bpm

• Flutes

• High Frequencies

• Nature sounds: Birds, rainforest

• Novel and Erratic

Calm/focus — olfactory

• Lavender

• Rose

• Rosemary

• Vanilla

Alert/stimulate — olfactory

• Lemon/Citrus

• Peppermint

• Eucalyptus

• Cinnamon

Calm/focus — gustatory

• Chewing

• Blowing

• Sucking

• Bland Flavors

• Sweet (flavor)

• Chamomile

• Lavender

Alert/stimulate — gustatory

• Crunchy

• Salty

• Sour

• Strong Flavors

• Cinnamon

• Peppermint

Sensory diet (lifestyle change)

A carefully designed, personalized activity plan that provides the sensory input a person needs to stay focused and organized throughout the day

The alert program - how does your engine run?

• High engine → over-aroused (hyper, anxious, overwhelmed)

• Low engine → under-aroused (tired, sluggish, unfocused)

• Just-right engine → ideal learning/engagement state

The zones of regulation

• Blue - sad, sick, tired, bored, moving slowly

• Green - happy, calm, feeling okay, focused, relaxed

• Yellow - frustrated, worried silly/wiggly, excited, lose of control

• Red - mad/angry, terrified, elated/ecstatic, devastated, out of control 

Major fine motor milestones — 4-5 years

Dynamic tripod grasp, prints name from copying, traces diamond, up to 20-piece puzzle

hand preference becomes fully established

Building upon basic hand skills — tool use - an extension of the arm, i.e., use of scissors

4 ½ - 5 years – can cut a square

Shift

Linear rotation on the finger surface for repositioning of the object on the pads of the fingers (rolling on fingertips) — sliding a pencil

Simple rotation

Turning an object held by the finger pads 90-degrees or less

Unscrewing a small bottle cap, reorienting a puzzle piece

Complex rotation

• Turning an object held by the finger pads 180-360 degrees with fingers alternating in producing the movement independent of one another

• Turning a coin in the hand or turning a pencil to use the eraser

Down syndrome (Trisomy 21)

• A condition in which a person has an extra chromosome on the 21st chromosome

• Mild to moderate intellectual disabilities

• Down syndrome can affect multiple body systems, leading to hearing and vision problems, sleep apnea, heart defects, low muscle tone, thyroid issues, and an increased risk of Alzheimer’s disease.

Key laws and policies governing EI

• Federally Mandated and State Regulated

• Focus on children from birth to age 3 who have developmental delays or disabilities.

• Importance of EI for maximizing potential during critical developmental periods.

EI policies - what you need to know

• Federally mandated

  • No cost to the families

  • Public Awareness and Child Find

  • Provides money to states who demonstrate compliance

• State-Regulated

  • Can be different in each state

  • Establish definition of “developmental delay”

PA’s developmental delay definition

• 25% delay (scored from standardized assessments)

• 1.5 SD below the mean

• Physical or mental diagnosis with high risk of DD

Individualized family service plan (IFSP)

Determined and created after a child has qualified for services (service coordinators) / Similar to an IEP in some ways

What does IFSP outline?

• Services to be received and the frequency

• Family-centric outcomes (goals)

• Collaborative development

• Plan for transition

• Written parental consent

Role of service coordinators

• Advocates for the family first

• Assist the therapist with other needs

• Ensures outcomes and treatment are targeted toward routines and are family-centric

What does treatment look like in EI?

Within the child’s environment, you’re working with what they have. Also think of getting out into the community like going to the pool, the playground, etc. 

You might see them mostly in daycare

Idea behind coaching (sitting on your hands)

• When parents have the ability to practice under the guidance of an “expert,” the likelihood that they will continue to use those strategies increases

• So, instead of receiving OT 1x/week, the child may receive OT 20x/week

What is a must in documentation?

Must include guided practice - coaching the parent to do something (can’t bill unless it is included)

Also include family plan for between sessions - what (target), how (strategies), when and where (routines and locations), who (which caregiver), what will success look like for the family?