Small Step Program for Early Intervention

The evidence base for effective early intervention for infants at risk of CP and DD is growing. Similar to the GAME approach the Small Step program emphasizes intensive training and the importance of infant initiated action to promote motor learning.  More about the GAME intervention 

A summary of the Small Step Program RCT report and intervention principles

Pam Versfeld 19 September 2019

Holmström, L., et al (2019). Efficacy of the Small Step Program in a Randomized Controlled Trial for Infants under 12 Months Old at Risk of Cerebral Palsy (CP) and Other Neurological Disorders. Journal of clinical medicine, 8(7), 1016.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6679038/

Eliasson AC et al Efficacy of the small step program in a randomised controlled trial for infants below age 12 months with clinical signs of CP; a study protocol. BMC Pediatr. 2016 Nov 3;16(1):175.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5093986/#CR30

Acknowledgement: In this summary of the Small Step RCT and proposal I have quoted extensively from the published articles.

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The Small Step RCT

This study evaluated the effects of the recently developed Small Step Program for infants at risk of developing CP and other neurodevelopmental disorders. Small Step was designed to include a combination of intervention elements to provide individualized, goal-directed, and intensive intervention addressing three distinct foci (i.e., hand use, mobility, and communication) provided in the child’s own home environment and conducted by their parents, who were trained and coached by therapists, and to be used from 4 months of age.

A randomized controlled trial compared Small Step with Standard Care in infants recruited at 4–9 months of corrected age (CA).

The 35-week intervention targeted mobility, hand use, and communication during distinct periods. Thirty-nine infants were randomized to Small Step (n = 19, age 6.3 months CA (1.62 SD)) or Standard Care (n = 20, age 6.7 months CA (1.96 SD)).

Outcome  Administering PDMS-2 at end of treatment identified no group effect, but an interaction between group and PDMS-2 at baseline was found (p < 0.02).

'There was no difference between the children who received the Small Step Program and those who received Standard Care in terms of their level of development at end of the intervention or at 2 years of age. However, the developmental level was influenced by the baseline status. In the Standard Care group, the infants who started with low ability improved less than did those who started somewhat higher, while infants in the Small Step group developed independent of their baseline level. This implies that Small Step helped the most affected children to catch up to the less affected children by the end of the treatment period, a result that was sustained at 2 years of age for PDMS-2 and the PEDI mobility scale. These results were robust when various models were tested to find the optimal statistical model. Diagnosis, CP or not, did not influence the results. The parents found the Small Step Program to be both feasible and acceptable.”

More about the Small Step Program

“The Small Step Program is an individualized, goal directed, and intensive intervention that focuses on hand use, mobility, and communication. The program is intended to be carried out in the child’s home environment and be conducted by their parents who are trained and coached by therapists. The program is designed be used from about 4 months of age and seeks to take advantage of the theoretically plastic period of brain development at this age. The program is designed to include and combine components that are known to be of importance in evidence-based intervention approaches for older children. The challenge in the Small Step Program is to adapt this knowledge and apply it within an intervention for very young children.”

The Small Steps intervention is based on several principles

1 Intervention is goal centered

“The goal-directed approach has been successfully used in older children [25, 26]. However, for families in a very vulnerable time period of life, with a young infant with high risk of developing CP, it is not easy to define goals in either the short or long-term perspective. In a goal-setting approach, the person’s own individual wishes are a strong ingredient, and it is suggested that the goals should be functional and meaningful for daily life. Such a goal-centred approach is taken in the Small Step Program, and collaboration between the parents and therapists will help the family to determine and focus on what their infant will likely be able to learn as a next step within the different foci and to define goals that are closely related to the child’s ability and cognitive level.”

2 There is a strong emphasis on children’s self-initiated actions, which are stimulated by meaningful and motivating activities and toys.

  • The stimuli should be clear and understandable for the child and should be related to the child’s developmental stage.
  • Training is adapted to the child's level of ability and is challenging but not too demanding
  • It is assumed that development is driven by children’s unique characteristics and capacity to explore a situation through which they discover new and more advanced activities.

3 Repetition and extensive practice is an important aspect of intervention

“It is well established that a task has to be well learned if it is to be performed effectively. Thus, it must be possible even for infants to experience that a particular task can be performed with ease and success, such as grasping a toy or keeping control of their gaze. “

“It has to be emphasized that training can only be performed as long as the infant finds it enjoyable because infants cannot be forced to perform self-initiated actions.

One of the overarching goals with the Small Step Program is thus to create a positive reflective atmosphere that promotes self-initiated actions and communication and communication in the child’s home environment. “

4 Maximizing the frequency of self-initiated motor activity in the child’s everyday environment is seen as an important factor supporting motor learning .

5 The Small Step intervention program is divided into 3 focus areas of hand use, mobility, and communication is to facilitate the learning process within each area.

“Typically, a child learns a lot within each area during the first year of life, and each focus area includes a huge amount of competence for parents as the training providers to capture. There is a limited amount of time during the day when a small child can attend to practice because caring and sleeping usually predominate their days. By introducing specific foci, we intend to help the family to optimize the training and to use their time as efficiently as possible. “ Training in hand function is first introduced, followed by mobility and communication.

6 Coaching of parents plays a prominent role in the Small Step Program. The aim is to provide a solution-focused approach that helps families to achieve goals that are unique and meaningful to them


More about the GAME approach
More about TOMT approach