Systematic Review of Interventions Used in Occupational Therapy to Promote Motor Performance for Children Ages Birth–5 Years

Developmental Play-Based Interventions for Infants at Risk

Five studies examined the effects of developmental interventions; 2 were systematic reviews, and 3 were randomized controlled trials (RCTs). Two of the developmental interventions were combined with other play-focused strategies (e.g., aquatic therapy, parent education). In these approaches, therapists analyze the child’s developmental level, encourage the next steps in play activities, and provide opportunities for the infant to transfer newly learned skills. With an understanding of the child’s emerging skills, the therapist provides appropriate supports to promote the child’s mastery of new skills. Often, therapists apply physical and social scaffolding to support the child’s performance at a higher level, reinforce the child’s efforts, and gradually fade supports (Case-Smith et al., 2010; Casey & McWilliam, 2011).

In an RCT of a developmental motor program for Thai infants (Lekskulchai & Cole, 2001), 84 preterm infants at risk for motor delays were randomly assigned to a therapy or control group. The intervention was a home program of 12 activities updated at 1, 2, and 3 mo adjusted age. At 4 mo adjusted age, the infants who received the home program scored significantly higher on the Test of Infant Motor Performance (Campbell, Kolobe, Wright, & Linacre, 2002) than those in the control condition and were similar to a group of infants who were not at risk.

The effects of another home-based therapy program emphasizing motor play on mother–child interaction and motor performance were analyzed in a sample of 38 mothers and infants with motor delays (Chiarello & Palisano, 1998). Infants (mean age = 19 mo) and mothers in the intervention group (n = 19) received five parent education sessions that included modeling activities to promote fine and gross motor skills in the context of positive, encouraging interactions; the control group (n = 19) received only usual care. Ratings using videotapes of mother–infant play showed that the interactions for both the control and the intervention groups were primarily positive and similar to each other (although mothers who participated in the intervention more appropriately held their infants).

McManus and Kotelchuck (2007) also involved families in a nonrandomized trial to examine the effects of aquatic therapy on young children (mean age = 15.8 mo) with a variety of motor disabilities. The intervention group received 36 wk of aquatic therapy (specific resistive movements in a pool) provided by an occupational therapist and physical therapist as a supplement to home-based occupational and physical therapy. The comparison group received only home-based occupational and physical therapy. Using the Mullen Scales of Early Learning (Mullen, 1995), the children who received aquatic therapy improved significantly more in functional mobility. McManus and Kotelchuck suggested that aquatic therapy is a community-based option that appears to benefit children’s motor function.

Two systematic reviews examined the effects of early intervention services on motor outcomes. Blauw-Hospers and Hadders-Algra (2005) examined the effects of early intervention on motor development in infants ages birth to corrected age of 18 mo. Of the 34 studies reviewed, 17 examined neonatal interventions and 17 examined interventions implemented post–neonatal intensive care unit (NICU). For the NICU interventions, 7 of 17 studies (2 Level I and 5 Level II) had significant positive effects on motor development. The Newborn Individualized Developmental Care and Assessment Program program (Als et al., 1994) had short-term effects on motor development, but long-term effects have not been found. Most interventions applied after the neonatal period were home-based and resulted in infants making limited motor gains. In 24 of 34 studies, parents were incorporated into the intervention; in 19, the parents were the focus of the intervention. Only 4 of 17 studies demonstrated a positive effect on motor development. These studies investigated developmental programs or specific motor training (e.g., treadmill training). Blauw-Hospers and Hadders-Algra concluded that the optimal interventions for motor development vary according to the age of the child and that the current approaches have minimal evidence in support.

Orton et al. (2009) concurred with these findings. They investigated the effects of early intervention programs on cognitive and motor development of preterm infants, with interest in both short-term (infancy) and long-term (school-age) outcomes. Of the 17 motor outcome studies, 8 with sufficient data analysis for meta-analysis showed a low effect (standardized mean difference = 0.07, p = .18) that was not significant. Of the remaining 9 studies, only 1 had a positive effect (i.e., Lekskulchai & Cole, 2001). Orton et al. concluded that the meta-analysis found no beneficial impact on motor outcomes at infancy or school age; however, because the interventions and measures were heterogeneous, the meta-analysis results should be viewed cautiously.

Interventions for Young Children With or At Risk for Cerebral Palsy

Occupational therapy is a primary intervention for children with CP, who often receive therapy services throughout early childhood. A range of interventions have been developed and tested, with varying levels of efficacy. We identified 15 studies of interventions for CP, 12 Level I and 3 Level II. One systematic review examined the effectiveness of upper-limb interventions for children with hemiparetic CP; the remaining studies examined the effects of NDT, constraint-induced movement therapy (CIMT), conductive education (CE), and context-focused intervention.

Sakzewski, Ziviani, and Boyd’s (2009) meta-analysis of therapy for children with hemiparesis (also termed unilateral CP) included 20 studies, 13 trials, and 7 systematic reviews that met their criteria. The studies included children of all ages; however, in most studies a portion of the sample were young children (<5 yr). Outcome measures included motor performance, progress on individualized goals, and self-care skills. The interventions used by occupational therapists fell into three categories: NDT, CIMT, and bimanual therapy. The meta-analysis revealed that children who received NDT improved in dissociated movements and individualized goals but not in motor function. CIMT and bimanual therapy are both intensive therapies for children with unilateral CP in which therapists use motor learning and behavioral (shaping) theories. CIMT trials have produced moderate to large treatment effects (see the next section); however, the measures often lack evidence of reliability and validity (Hoare, Imms, Carey, & Wasiak, 2007). The bimanual intensive treatment produced small effects. This meta-analysis set the stage for later trials comparing CIMT and bimanual interventions for children with unilateral CP (e.g., Sakzewski et al., 2011).

Visual–Motor Interventions for Preschool Children With Developmental Delays

Occupational therapists apply perceptual–motor and visual–motor interventions to promote preschool children’s prewriting skills. Visual–motor skills appear to be an important precursor to writing and in the young child are highly correlated with handwriting (Case-Smith, 1996; Dankert, Davies, & Gavin, 2003; Tseng & Murray, 1994). Four studies (3 Level II and 1 Level III) examined the effects of occupational therapy on visual–motor skill development in preschool children with visual–motor delays.

In a nonrandomized cross-over design, DeGangi et al. (1993) tested the effects of a child-centered versus a therapist-directed approach on visual–motor skills in 12 children (mean age = 53 mo). The children exhibited delays in fine motor skills, sensory processing, or motor planning. In the child-centered intervention, the child was allowed to explore his or her environment, dyadic interaction was emphasized, and the child selected the activity with therapist guidance. In the therapist-directed intervention, the sequence of activities was predetermined, and the therapist directed the activities and taught specific skills. Each child received 8 wk of one condition, was tested, and then received 8 wk of the other approach. The children in the therapist-directed intervention improved more in gross motor skills and functional skills. The children in the child-centered intervention improved more in fine motor skills. Behavior, attention, and play skills did not differ between groups. DeGangi et al. suggested that these two approaches are generally combined and that temperament, behavior, and affect may determine a child’s response to one therapy rather than the other.

In a second study that investigated the effects of service delivery method, Davies and Gavin (1994) compared the effects of individualized therapy services with those of group or consultation therapy services for preschool children with developmental delays. Using a sample of 18 preschool students with disabilities, they found that the children in the consultation model made similar gains on the developmental motor scales as the children who received individual therapy. Their gains in fine and gross motor skills were similar to those made by typical children (i.e., standard scores did not differ preintervention to postintervention). As in the previous study, clinicians often combined individualized therapy and group sessions in service delivery.

In a later study, Dankert et al. (2003) studied the effect of 1 yr of occupational therapy services on visual–motor skill development in a sample of preschool children with developmental delays (n = 12) compared with two comparison groups of children without developmental delays (one that received the intervention [n = 16] and one that received no intervention [n = 15]). An occupational therapist provided the intervention, which comprised fine motor, gross motor, and visual–motor activities. The children with delays who received intervention improved significantly pre- to posttest in visual–motor integration skills. These gains were larger (effect size = 1.15) than the gains made by the children without developmental delays who did not receive therapy (effect size = 0.16); they also made gains when standard (age-adjusted) scores were used. In a one-group pretest–posttest study, Case-Smith (2000) also examined the effects of occupational therapy services on fine motor and visual–motor outcomes. Using a sample of 44 children (mean age = 57 mos) with fine motor delays, the outcomes of 9 mo (23 sessions) of occupational therapy services were measured. Intervention comprised consultation (16%), individual sessions (62%), and group sessions (52%). The participants made statistically significant gains in manipulation, motor accuracy, fine motor, and visual–motor skills (ds = 1.83–2.13). The use of play and peer interaction within the therapy sessions predicted fine motor and visual–motor outcomes. This group of occupational therapy studies investigated service delivery models, including group versus individualized and child-centered versus therapist-directed. Although this group of studies had lower rigor (Levels II and III); the occupational therapy models demonstrated positive effects on fine motor and visual–motor performance in preschool children with mild to moderate disabilities.

Developmental Interventions for Infants

When providing services to infants and toddlers, developmental approaches in playful contexts are frequently used. Interventions typically involve the caregiver as a participant (e.g., Lekskulchai & Cole, 2001) or as the focus on the intervention (e.g., Chiarello & Palisano, 1998). An understanding of development is essential to designing interventions for all young children; however, designing activities that follow a developmental sequence may not be sufficient to affect clinically significant motor performance outcomes.

Most early motor interventions (e.g., those implemented when in the NICU) demonstrate short-term effects; however, evidence of long-term effects is minimal or missing. When interventions are applied to preterm infants who are at risk for developmental delays, all infants experience a neuromaturation process that may wash out intervention effects. Outcome measures represent averages for infants with neurological impairment, who may have benefited most from intervention, combined with those for infants who are neurologically intact. When examining motor outcomes of a variety of intervention approaches with infants, Blauw-Hospers and Hadders-Algra (2005) found that only a small portion (4 of 17 studies of intervention implemented post–neonatal period) showed evidence of positive effects. Most of these studies combined developmental approaches with other types of intervention (e.g., NDT, CE). Early developmental interventions demonstrated low effects when motor outcomes were later measured at school age, suggesting that developmental approaches may lack the potency needed to achieve significant effects (Blauw-Hospers & Hadders-Algra, 2005; Orton et al., 2009).

Despite lack of evidence for long-term gains, the benefits of short-term improvements in motor performance should be considered. Although not the focus of this review, researchers have found that when motor performance improves, infants achieve cognitive benefits (e.g., Bushnell & Boudreau, 1993; Orton et al., 2009). For example, when infants with motor delays improve in motor performance or mobility independence, such that they can explore and manipulate their environment, cognitive performance and socialization skills improve (e.g., Butler, 1986; Latash, 2000; Ragonesi, Chen, Agrawal, & Galloway, 2010). Therefore, motor performance improvements can lead to meaningful functional gains in other domains.

Interventions for Children With Cerebral Palsy

Trials of interventions for children with CP demonstrate mixed findings. NDT, despite its wide use by occupational and physical therapists, demonstrates low effects or effects that are similar to those of comparison interventions (Brown & Burns, 2001). As proposed by Bobath and Bobath (1984), when applying NDT, occupational and physical therapists inhibit the child’s abnormal muscle tone and guide the child to move in a normal developmental sequence. However, studies have shown that inhibition of tone through handling techniques does not appear to have long-term effects (Law et al., 1991). For certain daily activities, children with CP can be more functional when their movements do not resemble typical patterns. Butler and Darrah (2001) suggested that NDT lacks evidence of positive effects because its principles are based on the assumption that movement links only to the neural system, and NDT principles do not integrate current understanding of dynamic systems as the basis of movement. To develop an intervention based on principles of dynamic systems theory, Law et al. (2011) designed and tested a context-focused intervention, defined as a “functional, task-oriented and activity focused” approach (Darrah et al., 2011, p. 616). In context-focused intervention, the therapists collaborated with the child’s family to modify the tasks and environments in which the child functioned. Therapists encouraged the children to problem-solve new and challenging tasks using their unique (sometimes atypical) skills, accomplishing the task with a combination of mastered and emerging skills. Children used both trial-and-error approaches and “abnormal” movement to accomplish new tasks (Darrah et al., 2011). Children in the context-focused intervention made meaningful functional gains that were similar to those of children in the child-focused intervention. Law et al. (2011) suggested that efficacious interventions for young children with CP combine and balance child performance intervention with contextual adaptations.

Trials of CIMT demonstrate its benefit for young children with unilateral CP. Although our findings are based on only three RCTs, several other trials using older children concur that CIMT is an efficacious intervention (Eliasson, Krumlinde-Sundholm, Shaw, & Wang, 2005; Gordon, Charles, & Wolf, 2006; Gordon et al., 2011; Sakzewski et al., 2011). The active ingredients of CIMT—constraint of the less affected arm and intensive therapy using motor learning principles in functional, meaningful tasks—are both theory and research based (Taub, Uswatte, & Pidikiti, 1999). In CIMT, constraint of the less affected arm forces the child to attend to and rely on the more affected arm, resulting in extensive arm and hand use in everyday tasks. In most trials, the intensive therapy in CIMT ranges from 2 to 6 hr/day, with continuous constraint (i.e., casting) or constraint only during therapy sessions. As defined by Deluca et al. (2006), the child is challenged to attempt a new task with the involved arm that approximates his or her current skills. Attempts to accomplish higher level skills are encouraged and reinforced. Massed practice with fading reinforcement is used; challenging tasks are interspersed with mastered skills.

Although CIMT follows current understanding of motor learning and use of behavioral techniques, protocols for CIMT have not been clearly defined and vary across trials. An emerging type of therapy for children with unilateral CP eliminates the constraint and focuses on bimanual training (Charles & Gordon, 2006; Gordon, Schneider, Chinnan, & Charles, 2007). Bimanual training appears to have similar efficacy to CIMT but has not yet been tested in young children (Gordon et al., 2007; Sakzewski et al., 2011). In practice and in recent trials, CIMT and bimanual training are combined for a short-term intensive intervention period (e.g., 4–6 wk). The positive effects found in these studies suggest that short-term, intensive periods of intervention may have greater benefit than extended periods of low-dosage therapy 1–2 hr/wk.

Visual–Motor Interventions for Preschoolers

In early childhood programs, occupational therapists apply visual–motor interventions with young children who demonstrate visual–motor or fine motor delays. Generally, therapists use group and individual interventions with consultation focused primarily on prewriting and writing goals. In the four studies that examined the effects of visual–motor interventions, one was clinic based, three were administered in preschools, and all involved children with a variety of diagnoses and mild to moderate delays in visual–motor skills. Each study demonstrated positive effects on visual–motor skills. A therapist-directed, structured approach can produce greater improvement in gross motor skills, and a child-centered activity approach may result in more fine motor improvement (DeGangi et al., 1993). Two studies suggested that therapy sessions can leverage social elements to motivate the child and result in fine motor or visual–motor gains. Davies and Gavin (1994) found that group or consultation occupational therapy services are as beneficial as individual (one-on-one) sessions. Given that group and individual sessions have equal benefit, decisions about service delivery can be based on the child’s current developmental levels, behavioral issues, and contextual considerations. Case-Smith (2000) found that sessions that included peer interaction and play were related to visual–motor skill improvements. In group intervention sessions, therapists invite children of different performance levels and encourage peers to model for and reinforce the targeted child, to create a playful atmosphere, and to use peer support as a motivator.