Start with abilities, not disabilities and impairments 

TOMTI SF-EI  starts from the premise that  PT or OT  intervention should start with identifying what the infant is able to do, in other words, with her or his abilities, and use these as a the starting point for expanding the infant's range of abilities. 

There are many advantages to using this approach, not least of which is shifting the parents (and ourselves) towards a more positive appreciation of the infant's abilities.

The other immediate advantage of starting with what infants can do, is the opportunity to engage them in activities that lead to success, and set in train all the benefits that accrue from success, including increased motivation to move and explore, and activating the brain's reward mechanisms. 

The other important reason for starting with activities that the infant has at least partially mastered, is that developmental intervention should be guided by the  principle that development is a process of harnessing established abilities to support and serve as pathways to new learning. 

Developmental pathways and cascades 
Linda Smith defines a developmental pathway as a route, or chain of events, through which a new structure or function forms. For many human behaviors these pathways are often complex, multi-causal and include unexpected dependencies. 

She further defines development is activity-dependent change in a complex system. A tangle of successive causes and effects accumulate change over time and increase the structure and complexity of the developing system. 

The far reach of early developments on later ones is referred to as a developmental cascade. 

(Smith 2013 Smith, L. B. (2013). It’s all connected: Pathways in visual object recognition and early noun learning. The American Psychologist, 68(8), 10.1037/a0034185. http://doi.org/10.1037/a0034185)

Molly, 10 months, is not able to hold her head erect when supported upright 

My first question is: What can Molly do?  What motivates her? 

• When supported in sitting on her mom's lap, is she interested in looking at objects and people?  Does she reach out for toys?  Does she engage with me socially? 
• When sitting in a reclining seat, does she look around, will she reach for toys? 
• What does she do in supine on a firm surface? Is she reaching for toys?  Does she actively kick, and explore the supporting surface with her feet and hands? 
• What does she do when placed in prone?  

Observation and interaction with Molly highlighted her strengths

Molly is interested in her environment, and in postilions where her head is supported she looks around to see what is happening. She is particularly interested in novel and interesting, but gentle, sounds such as a plastic carrier bag being scrunched,  and ringing of bells. 

She is very interested in people and likes to engage with an animated social partner. 

When sitting with support around her chest  I can get her lift her head to look at me if I keep her attention by making very animated faces. 

When sitting in a reclining seat, she engages with her mom. 

I let Molly lie on a playmat and carefully observe the hand movements she makes.  Then I suspend a small balloon with a few rice grains in it, so that she knocks the ballon when she moves.  She quickly figures out the connection between her hand and the movement of the balloon, and increases her hand movements. I suspend a small, soft ball that is easy to grasp close by, and give her time to discover the new toy. 

I also tie a small bell to her left ankle, and watch her discover the link between her kicking actions and the tinkling of the bell. 

I let Molly sit in a chair with a back support and position a slightly inflated plastic carrier bag behind her head. When she lifts her head, the bag makes an interesting sound. She quickly discovers that if she keeps her head up and turns it from side to side, she can produce different sounds. 

What are Molly's abilities?
What is my starting point for developmental intervention? 

Molly is very interested in people, and with the right postural support is motivated to keep her head up to keep engaging with an animated social partner.  She watches faces intently, and will imitate mouth movements and sounds that are in her repertoire. 

Molly is especially interested in novel and interesting sounds from the environment. 

Molly quickly learns from activities that create an interesting connection between her actions and a response from the environment. 

Molly's home program 

Lots of time on her play mat, with toys carefully positioned so that she can bat and grasp them easily. 

Lots of time sitting on a caregiver's lap, with support around her chest and interesting objects placed at eye level to watch. Molly's sister Jenna is given the job of entertaining her and encouraging her to reach out for toys. 

Some time sitting with manual support around the chest and facing an animated social partner. 

What  has Molly learned from this assessment? 

Molly has learned that, with a bit of extra effort, she is able to interact with her environment in interesting ways. 

She has been given many opportunities to succeed at moderately difficult tasks, and her experience with success is motivating her to use her available abilities to explore her environment in a more active way. 

Repeated opportunities that encourage Molly to lift and stabilize her head will improve the strength and coordination of the neck muscles. 

Reference 
Smith L. B. (2013). It's all connected: Pathways in visual object recognition and early noun learning. The American psychologist, 68(8), 618–629. doi:10.1037/a0034185

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