FINANCIAL DISCLOSURE AACPDM 72 Jointly Advancing Motor … · Cognitive Development in Infants with Motor Delays Stacey Dusing, PT, PhD, PCS Virginia Commonwealth University Richmond,

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Jointly Advancing Motor and Cognitive Development in Infants with Motor Delays

Stacey Dusing, PT, PhD, PCS

Virginia Commonwealth University

Richmond, VA

Regina Harbourne, PT, PhD, PCSDuquesne University

Pittsburgh, PA

Michele Lobo, PT, PhDUniversity of DelawareNewark, DE

Sally Westcott McCoy, PT, PhDUniversity of WashingtonSeattle, WA

AACPDM Meeting 2018Cincinnati, OH, October 4 – 7, 2018

FINANCIAL DISCLOSUREAACPDM 72nd Annual MeetingOctober 9-13, 2018

1. Disclosure of Relevant Financial RelationshipsGrant support for all speakers from:

Department of Education, Institute of Education Sciences # R324A150103

2. Disclosure of Off-Label and/or investigative uses:

We will not discuss off label use and/or investigational use in our presentation.

Researchers & Participating SitesSTART-Play studyu Principal Investigators

u Regina (Reggie) Harbourne, Duquesne University

u James (Cole) Galloway, University of Delaware

u Co-Investigators

u Michele Lobo, University of Delaware

u Stacey Dusing, Virginia Commonwealth University

u Sarah (Sally) Westcott McCoy, University of Washington

u Jim Bovaird, University of Nebraska

u Sue Sheridan, University of Nebraska

Objectives

u Describe the continuum of changes in four cognitive constructs during infancy to eventual skills in later childhood.

u List how early movement (sitting, early mobility, reaching) in infancy directly depends on advancing cognitive and perceptual areas.

u Understand and give examples of how changing cognition evolves from early movement skill development.

u Apply the understanding of interaction between motor and cognitive changes to creating new approaches to intervention for specific types of children.

More Research Team Membersu Research Coordinators/Assistants

u Monica Smersh, UW

u Natalie Koziol, UNL

u Hui (Iris) Chang & Mihee An, DU

u Gullnar Syed, VCU

u Assessment team

u Jaclynn Stankus, Maddie Aubuchon, Cierra Maloney, Jamie Barnhill, DU

u Lin-Ya Hsu, Hoda Farhadi, Anne Ziegitrum, Whitney Gregory, UW

u Emily Marcinowski, Tanya Tripathi, VCU

u Iryna Babik, Andrea Cunha, UD

u Heidi Reelfs, Lynne Capoun, Emily Drew, UNMC

u Intervention therapists

u Lisa Hennen, Kelly Bossola, Meg Stanger, DU

u Shaaron Brown and Cathy VanDrew, VCU

u Tracy Stoner, Lisa Schwarcz, UD

u Allison Yocum, Shawn Israel, Brooke Fitterer, UW

u Sandy Willett, Amy Beyersdorf, UNMC

Plan

u Successful movement therapy for infants (Sally)

u Cognitive-motor relationships & cognitive constructs important for early learning & intervention (Michele)

u Four cognitive constructs strongly related to movement (Reggie)

u Building a toolbox of activities - problem solving with cases (Stacey)

u Wrap-up (All)

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Early Intervention

u Early intervention services are well established and mandated throughout the United States, (IDEA Part C).

u The evidence that these services make a difference in developmental or educational outcomes for infants with neuromotor dysfunction, however, is variable and limited (Spittle et al, 2007; Spittle & Treyvaud, 2016).

Theoretical Premises of Early Intervention

u Plasticity of the brain in early life exists so need to intervene as soon as possible to limit the impact of delays

Theoretical Premises of Early Intervention

u Early experiences can have a long lasting effect on outcomes u School performance for children with low

socio-economic status (Barnett, 1995)

u Psychosocial skills of human infants (Cirulliet al, 2003)

u Motor and sensory skills (Kolb et al, 2004; Martin et al, 2007).

u Video from reggie

What we know about successful movement therapy for infants with or at risk for CP

u Systematic review of studies 1980-2015– (Morgan et al. 2016)u Effectiveness of motor interventions for children 0-2 years with

a dx of CP or high risk for CP

u Team reviewed 34 studies

u Moderate rigor studies: n=402u Duration of intervention: 6 weeks -12 months

u Intensity of intervention: 6 days/week for 6 weeks – monthly for 12 months

u Low rigor studies: n= 154u Most common intervention was NDT, but described in

various ways

What we know about successful movement therapy for infants with or at risk for CP

u Bottom line - weak evidence

u Possible successful ingredients of therapy : u Child-initiated movement (motor learning

principles)

u Environmental modification/enrichment (parental education)

u Task-specific training (motor learning principles)

u Need more research

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What we know about successful movement therapy for children with CP

u Novak et al., 2017

u Reviewed 6 systematic reviews & 2 evidence-based clinical guidelines

u Diagnosisu Early detection (before 6 months) should occur

u After diagnosis of CP or high risk for CP, determination

of unilateral vs. bilateral

What we know about successful movement therapy for children with CP (Novak et al., 2017)

u Hemiplegic CPu CIMT– Constraint-Induced Movement Therapy - better hand function

(Eliasson & Holmefur, 2015

u Bilateral CPu Surveillance & intervention - lower rates of hip displacement,

contracture, scoliosis

What we know about successful movement therapy for children with CP (Novak et al., 2017)

u All children with CPu GAME – Goals-Activity-Motor Enrichment -

better motor & cognitive skills (Morgan et al. 2015)

uEarly, intense, enriched environment, task specific, training based home intervention

u Learning Games Curriculum (Palmer et al, 1988)

u Home based better then clinic based

u Parent Education

Intervention to improve motor and cognitive outcomesu Key ingredients: early, parent-infant interaction,

goal-oriented, active & task specific, environmentally appropriate

u Although early interventionists value early motor skills as goals, they focus often solely on motor milestones (Palisano,1991) without association to the cognitive implications of the movement (Mahoney &

Robinson, 2004).

u How do we remove our motor behavior blinders to provide intervention for long term improvement of educationally relevant outcomes?

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Define cognition

Discuss some relationships between motor behaviors & cognition

Define & discuss examples of cognitive constructs that are important for early

learning & impact our interventions

What is Cognition?

uProcess of acquiring knowledge & understanding through thought, experience, & the senses

uMotor, language, social, and traditionally-labeled cognitive learning & performance all fall under the umbrella of “Cognition”

Google Dictionary; Lobo et al., 2013; Thelen, 2000

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What Does That Really Mean?

uLearning to control your body, to interact with objects, to interact with people are all cognitive tasks

Lobo et al., 2013; Smith & Gasser, 2005; Thelen, 2000

Discuss some relationships between motor behaviors & cognition

Cognitive Ability &

Experience

Motor Ability &

Experience

Motor Experience Can Impact Cognitionu Head Control

u Head lifting prone & holding head midline in supine relates to Bayley III cognitive & language scores (as well as motor scores) birth-24 months

u Reaching

u Impacts understanding of cause-effect relations, how to interact with objects, interest in objects, understanding of others’ intentions to reach for objects

u Object Manipulation & Interaction

u Impacts knowledge of object segregation, color, weight, density, & cause-effect relations

Babik, in review; Lobo, 2008; Needham, 1998, 2011

Motor Experience Can Impact Cognitionu Sitting

u Increases looking at objects you are manually exploring

u Improves 3D object completion ability (knowing what to expect from parts of objects that cannot be seen)

u Locomotor experience

u Advances cognition for children with spina bifida or typical development – ability to represent space, to search in space, wariness of heights, gestural communication, distance perception, & social-emotional development

Campos et al., 2000, 2009; Needham & Libertus, 2011; Soska, 2010

Cognition May Also Impact Motor Performance

u Infants with more experience exploring objects learn to better match their behaviors to the properties of objects (e.g. shaking a rattle versus feeling a plush toy)

u Understanding of how things fit in openings impacts whether infants will attempt to reach through openings

u Infants with walking experience may better understand what their bodies can do and risk of falling

u More time exploring drop offs and slopes before navigating them

u May utilize alternative methods for navigation of steeper slopes or unstable surfaces (waterbed), such as scooting or crawling

Adolph, 1993; Ishak et al., 2013; Lobo, 2015

Cognitive constructs important for early learning & that may impact our

interventions

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Affect

uEmotion or desire, especially as influencing behavior

uPositive/Neutral affect – allows for attention to task & integration of information related to the task to facilitate learning

uNegative affect - keeps attention intrinsically on self & away from goal & negatively impacts motivation and learning

Google Dictionary; Shang et al., 2013

Attention

u Regarding of someone or something as interesting or important; the mental faculty of considering or taking notice of someone or something

u Better performance with external focus of attention on intended effect of action (e.g. hitting target, effect of tool use) versus internal focus on body movements/form

u Better performance with more distal than proximal focus of attention (e.g. on target object rather than tool, on flag at hole rather than on golf ball hitting)

u Able to focus more attention to cognitive tasks when the motor demand is less

u Greater perseveration (poorer success) in A not B locomotor task when walking on stairs versus walking on flat ground

Berger, 2004; Google Dictionary; Lewthwaite & Wulf, 2017

Motivationu Reason(s) one has for acting in a particular way; general desire or willingness

of someone to do something

u Perseverance: steadfastness in doing something despite difficulty or delay in achieving success; important component of motivation

u Can affect motor performance

u Extrinsic motivation – improved grip strength when offered monetary incentive

u Intrinsic motivation: infants with higher motivation (persistence, activity level) had earlier onset of sitting, pull to stand, crawling, and cruising and had higher percentile scores on AIMS

Atun-Einy et al., 2013; Google Dictionary; Meadows et al., 2016

Mastery Motivationu Just-right challenge matched to abilities so not too little (boredom and lack of

engagement) & not to be too great a challenge (frustration and lack of engagement)

u Need to educate parents on how to provide just-right opportunities

u Toddlers with motor delay did not show differences in persistence or pleasure when provided appropriately challenging tasks but parents rated them with motivation levels than did parents of TD toddlers

u Mothers of toddlers with motor delays provided less interactive behaviors to foster cognitive development than moms of toddlers with TD

u Expectations of parents impact opportunities provided and developmental timeline

u Parents in Jamaica expected their infants to sit and walk at earlier ages than did English parents and their expectations were fulfilled

Hopkins & Westra, 1989; Wang et al., 2013, 2014

Memory

u Faculty by which the mind stores and remembers information

u Enhanced expectancies result in better performance

u E.g. more success in golf task if first provided large hole versus small one for practice & therefore more success in practice

u Infants at risk may have impaired memory for solutions they have learned

Haley et al., 2008; Heathcock et al., 2004; Google Dictionary; Lewthwaite & Wulf, 2017; Rovee, 1969

Theoretical Model of Change

Skilled Sitting

Skilled Reaching

Problem solvingGlobal

Development and Readiness to Learn

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Cognitive Constructs and Action

uMeans – End

uObject Permanence

uObject/Body Affordances

uJoint Attention

MEANS-END

uActing on one object so that something happens on another object

uEarly cause-and-effect type of learning

uRelated to tool use

uRelationship of body posture, reaching, grasping, adapting body to object, visual regard, focused attention

Means-End change over time Predictive expectation

u Infants very early (prior to 6 months) learn patterns of eventsu Hear a sound, see the object that makes that

soundu See a moving object go behind something, expect

it to come out on the same trajectoryu The relationships of events with sensorimotor

activity (active movement) build a brain – creates synapses of related brain areas – “what fires together wires together”

OBJECT PERMANENCE

uThe understanding that objects continue to exist even when they can’t be seen (felt, smelled, heard…)

uRelated to independent mobility

uAlso related to visual pursuit, memory, sitting and reaching, manipulation of objects

uTied to understanding spatial concepts (under, in, behind)

Object permanence change over time

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OBJECT AFFORDANCES

uThe relationship between an organism and an object that allows an action to be performed

uRequires maneuvering body segments around, between, over, under objects

uRelates properties of objects (squishy, texture, weight, shape) to what can be done with the object

JOINT ATTENTION

uCoordination of attention with a social partner to some third object or event

uImportant precursor to language

uRequires looking back and forth quickly, following the gaze of another person, orienting of the body to the interesting object

EXAMPLES OF COGNITIVE CONSTRUCTS WITH VARYING MOTOR DIFFICULTIES



COGNITION-ACTION TRADE OFF

uEffortful physical tasks can impose a cognitive load

uEfforts to accomplish a cognitive task may require reduction of physical effort

uAttention is a limited resource which must be allocated appropriately depending on the function, task, and environmental support

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Example of cognition-action trade-offCase Studies and Discussion

u Videos of early intervention, outpatient, and START_Play interventions of the same child working on the same skills will be shared

u Attendees will reflect on the interventions in the video and consider u What was the focus of this intervention

u What this child using his cognitive skills

u What did the therapist do to support motor and cognitive development

u What would you do differently in order to enhance utilization of the cognitive constructs presented in this session

u Parents will talk about how the intervention impacted their child

Sitting and Prone Play

u This case shows video of child who is learning to sit, transition in and out of sit, and use prone mobility to explore

u He has a developmental delay and a rare genetic Dx that puts him at high risk of cognitive impairment. He was 15 months at enrollment.

u His parents goals are for him to learn and play as much as his can

Prone MobilityØ What was the focus of this

intervention

Ø Was this child using his cognitive skills

Ø What did the therapist do to support motor and cognitive development

Prone mobilityØ What was the focus of this

intervention



Prone mobilityØ What was the focus of this

intervention



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What ideas do you have about the intervention you would use to enhance his cognitive and motor skills?

Reaching and Rolling

u This case shows video of child who has a significant motor disability and is learning to reach and roll.

u He has a developmental delay, a seizure disorder, and cleft lip. He does not have a known Dx

u His parents goals are for him to interact with them and be able to reach and play more consistently


Ø What was the focus of this intervention

Ø What is this child doing to use his cognitive skills







Reaching and Sitting

u This case shows video of the same child who has a significant motor disability and he is working on sitting.

u He has a developmental delay, a seizure disorder, and cleft lip. He does not have a known Dx. He was 10 months when he started the intervention.

u His parents goals are for him to interact with them and be able to reach and play more consistently

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Sitting and Exploring Toys





Pulling to Stand

u This case shows video of the same child that was in the first video now working on pulling to stand to play with toys.

u He has a developmental delay and a rare genetic Dx that puts him at high risk of cognitive impairment

u His parents goals are for him to learn and play as much as his can

Pulling to stand





What do parents say about START_Play

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Take home messages:Interventions should be designed around a targeted goal that bridges domains of development. START-Play strives to advance problem-solving through movement and exploration.

START-Play Key ingredients are based on current evidence: early, parent-infant interaction, goal-oriented, active & task specific, environmentally appropriate

Take home messagesWhat can you do tomorrow?•Identify the problem-solving skills of one child on your case load•Come up with 3 ways you can set up play to practice a slightly harder problem solving skill making it easy (what they can already do) / mod / hard.•Think about 3 levels of motor challenge (easy/mod/hard) for that child•Set up practice for this child to try the problem solving and motor skills at the same time by varying the levels•Give the child time to respond – i.e. do not help too fast; allow variability and errors

Take home messages

- Can best foster learning during play by:• choosing tasks that provide the just-right level of

challenge in motor and cognitive areas together• are motivating, by encouraging exploration with

attention to the end goal (may use cues to elicit joint attention for this)

• working at times of positive or neutral affect, and• providing repeated opportunities for infants to

problem-solve in order to advance learning

Key Referencesu Barnett, WS. Long-term effects of early childhood programs on cognitive and

school outcomes. The Future of Children: Long-Term Outcomes of Early Childhood Programs.1995;5:25-50.

u Cirulli, F, Berr, A, Alleva E. Early disruption of the mother-infant relationship: effects on brain plasticity and implications for psychopathology. Neurosci BiobehavRev. 2003;27:73-82.

u Eliasson AC, Holmefur M. The influence of early modified constraint-induced movement therapy training on the longitudinal development of hand function in children with unilateral cerebral palsy. Dev Med Child Neurol. 2015;57(1):89-94.

u Kolb B, Gibb R, Robinson TE. Brain plasticity and behavior. In J. Lerner & A.E. Alberts (Eds), Current Directions in Developmental Psychology, pp11-17. Prentice-Hall, Upper Saddle River: NJ.Mahoney & Robinson, 2004

u Martin JH, Friel KM, Salimi I, Chakrabarty S. Activity and use-dependent plasticity of the developing corticospinal system. Neuroscience Biobehavioral Review, 2007;31:1125-1135.

u Morgan C, Novak I, Dale RC, Guzzetta A, Badawi N. Single blind randomisedcontrolled trial of GAME (Goals–Activity–Motor Enrichment) in infants at high risk of cerebral palsy. Res Dev Disabil. 2016;55:256-267.

Key Referencesu Palisano, R. Research on the effectiveness of neurodevelopmental treatment.

Pediatr Phys Ther. 1991;3:143–148.

u Palmer FB, Shapiro BK,Wachtel RC, et al. The effects of physical therapy on cerebral palsy: a controlled trial in infants with spastic diplegia. N Engl J Med. 1988;318(13):803-808.

u Spittle A, Treyvaud K. The role of early developmental intervention to influence neurobehavioral outcomes of children born preterm. SeminPerinatol.2016 Dec;40(8):542-548.

u Spittle A, Orton J, Anderson P, Boyd R, Doyle LW. Early developmental intervention programmes post-hospital discharge to prevent motor and cognitive impairments in preterm infants. Cochrane Database Syst Rev. 2012 Dec 12;12:CD005495. Update in: Cochrane Database Syst Rev. 2015;11:CD005495.

u Novak I, MorganC, AddeL, Blackman J, Boyd R, et al. Early, accurate diagnosis and early intervention in cerebral palsy: Advances in diagnosis and treatment. JAMA Pediatr. 2017;171(9):897-907.

Referencesu Adolph, K. E., Eppler, M. A., & Gibson, E. J. (1993). Crawling Versus Walking Infants Perception of

Affordances for Locomotion over Sloping Surfaces. Child Development, 64(4), 1158-1174.

u Atun-Einy, O., Berger, S. E., & Scher, A. (2013). Assessing motivation to move and its relationship to motor development in infancy. Infant Behavior & Development, 36(3), 457-469. doi:10.1016/j.infbeh.2013.03.006

u Berger, S. E. (2004). Demands on finite cognitive capacity cause infants' perseverative errors. Infancy, 5(2), 217-238.

u Campos, J. J., Anderson, D. I., Barbu-Roth, M. A., Hubbard, E. M., Hertenstein, M. J., & Witherington, D. (2000). Travel broadens the mind. Infancy, 1(2), 149-219.

u Campos, J. J., Anderson, D. I., & Telzrow, R. (2009). Locomotor experience influences the spatial cognitive development of infants with Spina Bifida. Zeitschrift Fur Entwicklungspsychologie Und PadagogischePsychologie, 41(4), 181-188. doi:10.1026/0049-8637.41.4.181

u Dalton, J. C., Crais, E. R., & Velleman, S. L. (2017). Joint attention and oromotor abilities in young children with and without autism spectrum disorder. Journal of Communication Disorders, 69, 27-43. doi:10.1016/j.jcomdis.2017.06.002

u Feldman, R., Rosenthal, Z., & Eidelman, A. I. (2014). Maternal-Preterm Skin-to-Skin Contact Enhances Child Physiologic Organization and Cognitive Control Across the First 10 Years of Life. Biological Psychiatry, 75(1), 56-64. doi:10.1016/j.biopsych.2013.08.012

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u Hopkins, B., & Westra, T. (1989). Maternal expectations of their infants' development: Some cultural-differences. Developmental Medicine and Child Neurology, 31(3), 384-390.

u Ishak, S., Franchak, J. M., & Adolph, K. E. (2014). Perception-action development from infants to adults: Perceiving affordances for reaching through openings. Journal of Experimental Child Psychology, 117, 92-105. doi:10.1016/j.jecp.2013.09.003

u Landry, S. H. (1986). Preterm Infants Responses In Early Joint Attention Interactions. Infant Behavior & Development, 9(1), 1-14.

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u Lewthwaite, R., & Wulf, G. (2017). Optimizing motivation and attention for motor performance and learning. Current Opinion in Psychology, 16, 38-42. doi:10.1016/j.copsyc.2017.04.005

u Lobo, M. A., & Galloway, J. C. (2008). Postural and object-oriented experiences advance early reaching, object exploration, and means-end behavior. Child Development, 79(6), 1869-1890. doi:10.1111/j.1467-8624.2008.01231.x

Referencesu Lobo, M. A., Harbourne, R. T., Dusing, S. C., & McCoy, S. W. (2013). Grounding early intervention: Physical

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u Lobo, M. A., Kokkoni, E., Cunha, A. B., & Galloway, J. C. (2015). Infants born preterm demonstrate impaired object exploration behaviors throughout infancy and toddlerhood. Physical Therapy, 95(1), 51-64. doi:10.2522/ptj.20130584

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u Needham, A. (1998). Infants' use of featural information in the segregation of stationary objects. Infant Behavior & Development, 21(1), 47-75. doi:10.1016/s0163-6383(98)90054-6

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u Spittle, A., Orton, J., Anderson, P. J., Boyd, R., & Doyle, L. W. (2015). Early developmental intervention programmes provided post hospital discharge to prevent motor and cognitive impairment in preterm infants. Cochrane Database of Systematic Reviews(11). doi:10.1002/14651858.CD005495.pub4

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Documents

FINANCIAL DISCLOSURE AACPDM 72 Jointly Advancing Motor … · Cognitive Development in Infants with Motor Delays Stacey Dusing, PT, PhD, PCS Virginia Commonwealth University Richmond,