If an infant has reached the age of 12-15 months months and has not yet achieved independent sitting, some form of prone locomotion, is not yet starting to take weight on the LEs in supported standing, and is not showing the expected progress despite PT, one can assume two things:
- development is being hampered by the underlying atypical brain development
- the infant is not motivated to move due to factors inherent in the infant and/or the environment.
One can usually not do anything to change the underlying atypical brain development, but it is possible to influence the infant's motivation to move and explore, and to provide the opportunities and the right environment for infants to learn to perform age appropriate developmental tasks despite the atypical brain development. Learning new motor tasks requires repeated practice and the willingness to persist in the face failure, as well as the experience of success - all ingredients needed for becoming motivated to move.
The purpose of assessment
The purpose of your task oriented assessment of a child with developmental delay is to gain insight into, not only what the infant can and cannot do, but also what motivates the infant to move. Knowing what motivates the child allows you to plan your intervention activities and training strategies.
Your assessment also provides an opportunity to understand the child's social, cognitive, language and attention abilities, which all impact on the ability to master new motor tasks and learn from experience, imitation and instruction.
What to include in your assessment of movement tasks
The information gleaned from the reason for referral and the parent interview usually provides a guide to which abilities and tasks need to be assessed. Taking time to observe the infant moving about and playing in an environment that offers a range of opportunities for playing allows the therapist to gather information about the emotional,cognitive and attention factors that contribute to, or restrain motor learning.
Taken together this information guides the selection of abilitiesand tasks that need to be assessed.
1 Start with the question: what motivates this child?
Infants learn through experience, and the motivation to move is often driven by the desire to reach for, and explore, new and interesting objects. At 12-15 months typically developing infants have developed an extensive range of object handling abilities, and the range and sophistication of object play provides a window into their cognitive development.
By a year, infants are also motivated to engage with a social partner, play cooperative games, follow instructions and mimic actions. Taking time to play with an infant allows the therapist to get to know the infant, how best to keep him/her interested and engaged and willing to participate in therapy activities.
| For a infants with marked delay, this is a very important starting point: to succeed, all your intervention activities require the infant to be motivated to move and persist to achieve a goal. |
How to do this. One way to find out what motivates a child, is to start with the infant in a well supported sitting or semi reclining position.
Position yourself opposite the infant and engage the infant socially. What sparks the infant's interest? Funny faces, talking, singing, pointing to interesting objects.
Present toys within easy reach and watch the infant's responses. Does he look at the toys, does he watch the toy if it is moved, does he reach for the toy, does he like watching a tower of blocks being knocked over, does he reach for a toy puppet, does he watch a rolling ball, does he bat at a suspended ball.
2 Assess hand use for interacting with objects and situations
Infants are often motivated to move because they wish to interact with interesting objects - and this in turn is powered by their ability to reach for, grasp and manipulate objects of different sizes, shapes and properties. Understanding object properties and potential uses (affordances) is learned through experience. Infants who are not able to sit independently and move around on the floor will often have very limited experience interacting with objects.
How to do this. With the infant reclining in an infant seat or in supine present a range of age appropriate toys for the infant to grasp, move and manipulate.
More information: Hand function 7-15 months: overview and How infants use their hands to grow thier minds
3 Assess the infant's abilities when sitting on a parent's lap
Infants will usually spend time sitting on a parent or caregiver's lap - so it is important to understand how this activity is being used to promote or hinder the infant's abilities in supported sitting.
How to do this: With the child sitting on the parent's lap, observe the parent and the infant's actions and responses.
How much support provided and how much is needed? What level of trunk support is needed? Is the child able to support the head when the trunk is tipped forwards? Will the infant reach for toys when sitting supported on the caregiver's lap?
Let the parent adjust the amount of support that is provided. Can the infant maintain a steady head and trunk with less support than is usually given?
4 Assess sitting with support
How to do this: Provide the child with manual support at the level of the axilla in sitting on a flat surface. Is the infant able to hold the head erect even briefly? With your face level with the infant's face, engage the infant socially. Does visually focussing on an interesting object help the infant to sustain head control?
If the infant can keep the head erect with manual support at the level of the axilla, move your hands to mid-throracic level. Can the infant still maintain the head erect with extension extending to the thoracic spine?
More information for subscribers: Sitting: development, assessment, training
Assess standing with support
If the infant is able to hold the head erect when supported upright in sitting, it is important to assess the child's ability to take weight on the LEs when supported erect.
How to do this. Support the infant in the upright position with the feet on a firm support surface with manual support under the axillae or at mid-thoacic level.
Notice whether the infant extends the hips and knees and attempts to support weight on the LEs.
For subscribers: Standing: development, assessment, training
Assess actions in supine
Infants who are not yet sitting independently need to spend time in supine on a firm surface as this is the one position in which they can experience independent movement. Encouraging active kicking, bridging, rolling and reaching in supine provides an opportunity for increasing neck and trunk muscle activity and potentially also stability.
How to do this. Observe the infant when lying supine. Talk or sing to the infant to raise the level of arousal, and observe changes in behavior. Bells attached to the leg, or plastic shopping bag in a pillow case under the LE provide interesting feedback when the LEs are moved.
Assess actions in prone and kneeling at a block.
Infants with marked developmental delay will usually not like lying in prone, especially if they have weakness in the neck and thoracic extensors. Often the best way to encourage being prone and taking weight on the UEs is to let the infant kneel facing a low step.
More information for subscribers: Kneeling and prone kneeling activities