Abstract
Through this Practice Guideline, the American Occupational Therapy Association (AOTA) aims to help occupational therapists and occupational therapy assistants, as well as the people who manage, reimburse, or set policy regarding occupational therapy services, understand occupational therapy services provided to children in the early childhood years (i.e., children ages birth–5 yr) and their families. This guideline can also serve as a reference for families, child care providers, early childhood teachers, early childhood special education (ECSE) teachers, education administrators, health care professionals, health care facility managers, health care regulators, third-party payers, managed care organizations, and those who conduct research to advance care of children ages birth–5 yr.
This guideline was commissioned, edited, and endorsed by AOTA without external funding being sought or obtained. The report was financially supported entirely by AOTA and was developed without any industry involvement. AOTA’s Evidence-Based Practice (EBP) Program is based on the principle that the EBP of occupational therapy relies on the integration of information from three sources: (1) clinical experience and reasoning, (2) preferences of clients and their families, and (3) findings from the best available research. The authors of the systematic reviews (SRs) and this Practice Guideline have signed a conflict of interest statement indicating that they have no conflicts that would bear on this work. AOTA aims to update practice guidelines every 5 yr to keep recommendations on each topic current according to criteria established by ECRI (2020). Guideline topics are evaluated for their currency on a 5-yr basis by a multidisciplinary advisory group consisting of member and nonmember content experts and external stakeholders. In addition, a preliminary search of the literature is conducted to see whether an updated systematic review is warranted.
This Practice Guideline reports the findings from published scientific research; interventions that did not emerge from the published literature or that did not meet the inclusion criteria are not included. Ultimately, occupational therapists make a judgment regarding the appropriateness of a given intervention in light of a specific person’s or group’s circumstances and needs and the evidence available to support the intervention.
Clinical Recommendations
Table 1 summarizes the clinical recommendations for occupational therapy practice in early childhood with children ages birth–5 yr. These recommendations were developed after completion of the SRs and full analysis of the data collected and are to be used to guide practice. AOTA uses the grading methodology provided by the U.S. Preventive Services Task Force (2018) for clinical recommendations:
A: There is strong evidence that occupational therapy practitioners should routinely provide the intervention to eligible clients. Good evidence was found that the intervention improves important outcomes and that benefits substantially outweigh harms.
B: There is moderate evidence that occupational therapy practitioners should routinely provide the intervention to eligible clients. There is high certainty that the net benefit is moderate, or there is moderate certainty that the net benefit is moderate to substantial.
C: There is weak evidence that the intervention can improve outcomes. It is recommended that the intervention be provided selectively on the basis of professional judgment and client preferences. There is at least moderate certainty that the net benefit is small.
I: There is insufficient evidence to determine whether occupational therapy practitioners should be routinely providing the intervention. Evidence that the intervention is effective is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.
D: It is recommended that occupational therapy practitioners not provide the intervention to eligible clients. At least fair evidence was found that the intervention is ineffective or that harms outweighs benefits.
Table 1 provides letter grades for interventions described in this Practice Guideline. The grades can help practitioners understand at what level they can feel confident to use the interventions. Describing the strength of clinical recommendations is an important part of communicating an intervention’s efficacy to clinicians and other users. As always, research evidence needs to be considered in conjunction with client needs and goals as well as sound clinical reasoning from experience.
Clinical Recommendations for Occupational Therapy for Early Childhood: Birth–5 Years
Note. Criteria for level of evidence and recommendations (A, B, C, I, D) are based on standard language from the U.S. Preventive Services Task Force (2018). Recommendations are based on the available evidence and content experts’ clinical expertise regarding the value of using such evidence. ADHD = attention deficit hyperactivity disorder; ADLs = activities of daily living; ASD = autism spectrum disorder; BIT = bimanual intensive therapy; CIMT = constraint-induced movement therapy; CP = cerebral palsy; EI = early intervention; GAME = Goals–Activity–Motor Enrichment; IBAIP = Infant Behavioral Assessment and Intervention Program; KC = kangaroo care; LEAP = Learning Experiences–An Alternative Program for Preschoolers and Parents; NICU = neonatal intensive care unit; NIDCAP = Newborn Individualized Developmental Care and Assessment Program; OT = occupational therapy; PCIT = Parent–Child Interaction Therapy; REDI = Research-Based Developmentally Informed.
Overview
The foundation for play, self-care, social interactions, academics, and self-regulation is built during the early childhood years as cognitive, motor, social–emotional, and self-care skills are developing. When young children and their families lack opportunities to participate in these essential daily habits and routines, they may experience limitations in their overall health, well-being, or quality of life. Barriers to participation may be associated with health conditions (e.g., asthma), disabilities (e.g., cerebral palsy [CP]), or environmental or social determinants of health (e.g., lack of accessible and safe neighborhood playgrounds, poor access to health care). Early identification of developmental delays and conditions is essential to intervene early to produce positive effects on development, academic skills, social interactions, and employment. Examples of common conditions in early childhood include high risk factors (low birthweight [LBW], prematurity), developmental delays, CP, Down syndrome (DS), autism spectrum disorder (ASD), attention deficit hyperactivity disorder (ADHD), and feeding disorders.
Occupational therapists identify early signs of delay and provide necessary screening, evaluation, and intervention services. During the evaluation and intervention process, occupational therapy practitioners use professional judgment and clinical reasoning to identify the client’s strengths and needs. Young children are dependent on adults, so forming a partnership with families, caregivers, teachers, and relevant others is essential. Although each child may have various types of caregivers, for the purpose of this guideline, we use the term parent for the primary caregiver. Family-centered services, a key feature in early childhood, include the parents as the ultimate decision makers for the child and focus services on the family’s strengths and resources as a whole, not just the child’s. As a child enters preschool, a collaborative student-centered approach is used (e.g., a focus on the child as a student and the child’s strengths and needs to meet the demands of academic and extracurricular activities).
To support engagement and participation in daily living activities (i.e., occupations), occupational therapy services may include evaluating the child to analyze occupational strengths and needs, planning with and educating the family, making adaptations to the environment, and intervening within the natural context and routine. On the basis of funding sources and payer requirements, children and families may access occupational therapy services in many environments such as the hospital (including the neonatal intensive care unit [NICU] and inpatient and outpatient services), home (including early intervention [EI]), and community (including preschool, Head Start, playgroups). Collaboration and communication among the family and all professionals are essential to enhance the child’s ability to participate in occupations.
Method
A major focus of AOTA’s EBP Project is an ongoing program of systematic review of multidisciplinary scientific literature, using focused questions and standardized procedures to identify occupational therapy–relevant evidence and discuss its implications for practice, education, and research. An evidence-based perspective is founded on the assumption that scientific evidence for the effectiveness of occupational therapy intervention can be judged to be more or less strong and valid according to a hierarchy of research designs, an assessment of the quality of the research, or both.
This Practice Guideline was developed with input from a wide variety of groups. Content experts, a medical librarian, non–occupational therapy professionals, and AOTA EBP Project staff, including a research methodologist, developed the protocol. A group of internal and external stakeholders comprising multidisciplinary providers, content experts, a research methodologist, professional association representatives, regulatory and policy content experts, and representatives of the target population reviewed the final guideline. The external review process consisted of a full manuscript review with a feedback form containing question prompts for the following information:
Each reviewer’s overall rating of the guideline and suggestions for improvements
Whether any content in the guideline is outdated, irrelevant, or in conflict with the reviewer’s experience and knowledge
Whether the guideline is representative of client-centered care and effectively communicative of best practice and EBP
Whether any topics are missing
Whether the guideline is understandable and accessible
Whether the guideline provides non–occupational therapy practitioners sufficient information about the role of occupational therapy and the topic.
External reviewers were given the choice to remain anonymous or be identified to the authors, and they were given the option of making additional comments directly on the manuscript.
Evidence Evaluation
AOTA uses standards of evidence modeled on those developed in evidence-based medicine (Sackett, 1989; Sackett et al., 1996). This model standardizes and ranks the value of scientific evidence for biomedical practice as follows:
Level I—Systematic reviews of the literature, meta-analyses, and randomized controlled trials (RCTs). In RCTs, participants are randomly allocated to either an intervention or a control group, and the outcomes for the groups are compared.
Level II—Two groups, nonrandomized studies (e.g., cohort, case control)
Level III—One group, nonrandomized studies (e.g., before and after, pretest–posttest)
Level IV—Descriptive studies that include analysis of outcomes (single-subject design, case series)
Level V—Case reports and expert opinion, including narrative literature reviews and consensus statements.
The SRs on children ages 0–5 were supported by AOTA as part of the EBP Project. A previous review covered 1990–2010 (Case-Smith, 2013; Case-Smith et al., 2013; Frolek Clark & Schlabach, 2013; Howe & Wang, 2013; Kingsley & Mailloux, 2013). For the current SRs, the literature search covered May 2010–March 2017. The SRs focused on questions developed and reviewed by the review authors; a multidisciplinary guideline development group of experts in the field that included practitioners, academic faculty, researchers, policymakers, and AOTA staff; and the research methodologist for the AOTA EBP Project. Four focused questions on occupational therapy interventions for children ages 0–5 yr framed the individual reviews:
What is the evidence for the effectiveness of interventions within the scope of occupational therapy practice to promote cognitive development and prevent further delay for children ages 0–5 yr?
What is the evidence for the effectiveness of interventions within the scope of occupational therapy practice to improve mental health and positive behavior for children ages 0–5 yr and their families?
What is the evidence for the effectiveness of interventions within the scope of occupational therapy practice to promote motor development and prevent further delay for children ages 0–5 yr?
What is the evidence for the effectiveness of interventions within the scope of occupational therapy practice to support activities of daily living (ADLs), rest, and sleep for children ages 0–5 yr and their families?
Search Terms
Search terms for the reviews were developed by the research methodology consultant to the AOTA EBP Project and AOTA staff, in consultation with the review authors for each question, and by the advisory group (i.e., content experts). The search terms were developed not only to capture pertinent articles but also to ensure that the terms relevant to the specific thesaurus of each database were included.
Table 2 lists the search terms related to population, interventions, and study designs included in the SRs. A medical research librarian with experience in completing SR searches conducted the searches and confirmed and improved the search strategies. The librarian exported the search results into EndNote (Version 8; Clarivate Analytics, Philadelphia). The research methodologist did the first review of the search results, eliminating all citations not relevant to the project. The results were then exported to the review authors in three formats: EndNote, Microsoft Word 2010 (Microsoft Corp., Redmond, WA), and tab-delimited formats.
Search Terms for the Systematic Reviews of Occupational Therapy Interventions for Children Ages 0–5 Yr
Note. DIR = Developmental, Individual differences, Relationship model; NIDCAP = Newborn Individualized Developmental Care and Assessment Program.
Databases Searched
Databases and sites searched included MEDLINE, PsycINFO, CINAHL, Cochrane, and OTseeker. Moreover, reference lists from articles included in the SRs were examined for potential articles, and selected journals were hand searched to ensure that all appropriate articles were included.
Inclusion and Exclusion Criteria
Inclusion and exclusion criteria are critical to the SR process because they provide the structure for the quality, type, and years of publication of the literature that is incorporated into a review. The reviews were limited to peer-reviewed scientific literature published in English. The intervention approaches examined were within the scope of practice of occupational therapy for children ages 0–5 yr. Participants were children ages 0–5 yr. Studies were excluded if they were dissertations, theses, presentations, proceedings, or outside the date range (May 2010–March 2017); had an older population; or were outside the scope of occupational therapy. Studies included in the reviews provide Level I, II, III, and IV evidence; studies providing Level IV evidence were included only when higher level evidence on a given topic was not found.
Overview of Search Results
The search located a total of 89,461 citations and abstracts. The research methodologist completed the first step of eliminating references on the basis of citation and abstract, removing duplicates and studies clearly not within the parameters of the review. This first review reduced the number of citations to 5,312, which were given to the review teams.
The SRs were carried out by teams of two or more reviewers. These teams completed the next step of eliminating references on the basis of citations and abstracts. The full-text versions of potential articles were retrieved, and the review teams determined final inclusion in the reviews on the basis of predetermined inclusion and exclusion criteria.
A total of 196 articles were included in the final review—137 Level I, 28 Level II, and 29 Level III studies, as well as 2 Level IV studies (Table 3). The teams reviewed the articles for their focused question according to quality (scientific rigor, risk of bias) and level of evidence. Finally, the review teams synthesized and reported the results of the included articles (see Gronski & Doherty, 2020; Kingsley et al., 2020; Tanner et al., 2020). Three SRs, with evidence tables and risk-of-bias tables, were published in the March/April 2020 issue of the American Journal of Occupational Therapy:
Gronski, M., & Doherty, M. (2020). Interventions within the scope of occupational therapy practice to improve activities of daily living, rest, and sleep for children ages 0–5 years and their families: A systematic review. American Journal of Occupational Therapy, 74, 7402180010. https://doi.org/10.5014/ajot.2020.039545
Kingsley, K., Sagester, G., & Weaver, L. L. (2020). Interventions supporting mental health and positive behavior in children ages birth–5 yr: A systematic review. American Journal of Occupational Therapy, 74, 7402180050. https://doi.org/10.5014/ajot.2020.039768
Tanner, K., Schmidt, E., Martin, K., & Bassi, M. (2020). Interventions within the scope of occupational therapy practice to improve motor performance for children ages 0–5 years: A systematic review. American Journal of Occupational Therapy, 74, 7402180060. https://doi.org/10.5014/ajot.2020.039644
Number of Articles Included, by Topic
Results from the review on cognitive interventions were published as Critically Appraised Topics and are available at https://www.aota.org/Practice/Children-Youth/Evidence-based/EBP-EI.aspx. (The evidence tables created from that review are available with this article as supplemental materials; navigate to this article at https://ajot.aota.org and click on “Supplemental”):
Frolek Clark, G., Fischbach, J., Crane, T., Corry, J., & Nadolny, E. (2019). Occupational therapy and team-led cognitive development interventions for premature and developmentally delayed infants: Systematic review of related literature from 2010 to 2017 [Critically Appraised Topic]. Bethesda, MD: American Occupational Therapy Association.
Frolek Clark, G., Fischbach, J., Crane, T., Corry, J., & Nadolny, E. (2019). Parent-implemented cognitive development interventions for children and youth 0–5 years: Systematic review of related literature from 2010 to 2017 [Critically Appraised Topic]. Bethesda, MD: American Occupational Therapy Association.
Frolek Clark, G., Fischbach, J., Crane, T., Nadolny, E., & Corry, J. (2019). Cognitive interventions implemented in preschool classrooms for children and youth 0–5 years: Systematic review of related literature from 2010 to 2017 [Critically Appraised Topic]. Bethesda, MD: American Occupational Therapy Association.
Frolek Clark, G., Fischbach, J., Crane, T., Nadolny, E., & Corry, J. (2019). Occupational therapy and team-led cognitive development interventions for preschool-aged children: Systematic review of related literature from 2010 to 2017 [Critically Appraised Topic]. Bethesda, MD: American Occupational Therapy Association.
Strength of Evidence
For each SR, the evidence was grouped into themes and described according to the strength of the evidence. Strength-of-evidence designations include a synthesis of level of evidence (I–IV), quality of evidence (risk of bias), and findings of the studies (significance of findings). By synthesizing these three evaluations, the review authors provide important information to practitioners in terms of the level of certainty that the interventions result in the outcomes shown. The strength-of-evidence levels are outlined in Table 4 and are based on the guidelines of the U.S. Preventive Services Task Force (2018).
Strength of Evidence
Note. The determination of the strength of evidence is based on the guidelines of the U.S. Preventive Services Task Force (2018; https://www.uspreventiveservicestaskforce.org/Page/Name/grade-definitions).
Benefits and Harms
This Practice Guideline is based on findings from SRs of interventions for children ages birth–5 yr that were produced for AOTA. The studies that met the inclusion criteria for the SRs did not explicitly report potential adverse events associated with the interventions evaluated in these studies. If harms were noted, they would have been explicitly reported in the summary of key findings and would have been taken into account in the determination of the recommendations. Before implementing any new intervention with a client, it is always prudent for occupational therapy practitioners to be aware of the potential benefits and harms of the intervention.
Clinical Reasoning
Occupational therapy practitioners exercise clinical reasoning that is based on a sound evaluation of the client’s strengths and limitations, values, preferences, and goals and an understanding of the intervention to determine the potential benefits and harms of that intervention for the individual client. Clinical reasoning is also required to translate the intervention protocols used in the reviewed studies into client-centered, clinically feasible interventions.
Interventions Enhancing Cognitive Development
Cognitive delays can affect a child of any race, ethnicity, gender, and socioeconomic class. Certain groups of children (e.g., those with medical or genetic conditions, who are homeless, or who are at the poverty level) are especially at risk (Hebbeler et al., 2007) for cognitive delays as a result of lack of proper prenatal care, poor nutrition, and trauma experienced within their social context. Infants who are born premature are surviving at higher rates, but their risk of brain pathology and impairments (Volpe, 2009) and cognitive and behavioral deficits, including reduced attention and executive function (EF; Delobel-Ayoub et al., 2009; Mulder et al., 2009), is high compared with term infants. Because cognition is the foundation for learning and interactions, delays can affect early developmental skills, including attention, memory, imitation, initiation, problem solving, object relations, and causality.
The ability to hold onto and temporarily manipulate information, known as working memory, is considered a precondition for EF. Impairment of this ability has been linked to academic difficulties in childhood, adolescence, and adulthood (Mulder et al., 2010, 2011). Significant risk to learning, behavior, and social interactions can be linked to cognitive deficits (Frolek Clark & Schlabach, 2013), and students with poor literacy skills are at risk for dropping out of school (Hernandez, 2012). The National Early Literacy Panel (2008) found several predictors of early literacy skills (e.g., recognizing letters and words, understanding print concepts) that were consistent even after controlling for socioeconomic status (SES) and IQ. These skills include knowing the names of letters, being able to break apart sounds, and writing letters or one’s name.
The question for this SR was, “What is the evidence for the effectiveness of interventions within the scope of occupational therapy practice to promote cognitive development and prevent further delay for children ages 0–5 yr?” (Frolek Clark, Fischbach, Crane, Corry, & Nadolny, 2019a, 2019b; Frolek Clark, Fischbach, Crane, Nadolny, & Corry, 2019a, 2019b). Fifty-four articles met the criteria for inclusion in the SR (Table 5). These articles included four intervention themes: (1) therapist led with premature infants, (2) therapist led with preschoolers, (3) parent implemented, and (4) implemented by a preschool team.
Evidence for Interventions for Cognitive Development
Note. N = 54. RCT = randomized controlled trial; SR = systematic review.
Theme 1: Therapist-Led Interventions With Premature Infants
Preterm births are currently estimated at 1 in every 10 infants born in the United States, with 17% of infant deaths in 2015 reported as infants who were preterm (especially before 32 wk) and with LBW (Centers for Disease Control & Prevention [CDC], 2018). Infants who survive may have conditions that affect cognitive development and learning. Occupational therapy practitioners work with families and other professionals to enhance the health and cognitive development of these young children.
Clinic- and Home-Based EI Programs
Fourteen studies, including 13 RCTs and 1 Level II study, provide strong evidence that clinic- and home-based EI programs can enhance cognitive development in infants born prematurely. Preterm infants demonstrated statistically significant improvements after the following programs: Newborn Individualized Developmental Care and Assessment Program (NIDCAP; Als et al., 2011, 2012, both Level I), home-based EI that trained parents to implement play and developmental activities with their child (Bann et al., 2016, Level I; McManus et al., 2012, Level II; Wallander, Bann, et al., 2014, Level I; Wallander, Biasini, et al., 2014, Level I), occupational therapy in a clinic-based program with a home-based activity program (Tang et al., 2011, Level I), and a clinic-based EI program focused on parent–child dyads (Wu et al., 2014, Level I).
In 2 Level I studies, the Infant Behavioral Assessment and Intervention Program (IBAIP) did not demonstrate a significant positive effect on children during follow-up at age 5.5 yr (Van Hus et al., 2016; Verkerk et al., 2012); a third Level I study did not find any difference in general cognitive abilities during follow-up at age 8 yr (Spittle et al., 2016). Three Level I studies provided no evidence that the Routines-Based Early Intervention (RBEI; Hwang et al., 2013) and Mother–Infant Transaction (MIT) programs (Kynø et al., 2012; Nordhov et al., 2010) significantly influenced preterm children’s cognitive development.
Theme 2: Therapist-Led Interventions With Preschoolers
This theme includes 4 Level I RCTs, 1 Level II study, and 6 Level III studies with a moderate risk of bias. Strong evidence supports providing cognitive training programs to preschoolers to enhance EF skills.
For example, young children with ASD increased cognitive skills after multidisciplinary developmental programs (Karanth et al., 2010, Level III) and maintained skills at the 6-mo follow-up after receiving pivotal response treatment (e.g., targeting of pivotal areas of the child’s development such as motivation or social initiations rather than one specific behavior) and positive behavioral support strategies (Smith et al., 2015, Level I). Preschoolers with ADHD who received cognitive strategies emphasizing attention, inhibition, eye–hand coordination, visual focusing, balance, sensory awareness, and listening skills (Tamm & Nakonezny, 2015, Level I; Tamm et al., 2014, Level III) or Cognitive–Functional group interventions from occupational therapists (Rosenberg et al., 2015, Level III) demonstrated statistically significant increases in EF.
Preschoolers with developmental delays showed significant improvement with individual or group interventions focused on developmental and sensory activities (Blanche et al., 2016, Level II; Golos et al., 2011, Level I; Lai et al., 2014, Level III; Sørensen et al., 2016, Level III). Preschoolers in a Level III study who were socially disadvantaged significantly increased cognitive skills after in-home training (Healthy Start Home Visit Program) was provided to parents (Leung et al., 2013). In a Level I study, increasing fantastical pretend play versus imaginative play significantly increased EF among preschoolers (Thibodeau et al., 2016).
Theme 3: Parent-Implemented Interventions
This theme includes 11 Level I RCT studies and 2 Level II studies with low risk of bias. Strong evidence from 3 Level I studies shows that cognitive abilities such as attention, working memory, and literacy skills can significantly improve when mothers read books to their young child (Cooper et al., 2014; Pillinger & Wood, 2014; Pratt et al., 2015). This theme focused on interventions that are carried out by the parent with minimal to no assistance after the initial training. Shared reading (e.g., parent–child interaction, which may include pointing at and naming pictures or commenting about the topic or picture) and dialogic reading (e.g., encouraging active participation from the child during book reading and adjusting reading style to fit the child’s language skills) were effective methods of book reading that resulted in significant outcomes.
Parent Education and Interactions
Strong evidence was also found that educating parents on interaction strategies significantly improves children’s cognitive development. These strategies included playing with the child (10 min daily for 5 days/wk over 3 mo; Tachibana et al., 2012, Level I), parenting programs that emphasize education and interaction (Aboud et al., 2013; Chang et al., 2015; both Level I), and feeding the child on demand versus a schedule (Iacovou & Sevilla, 2013, Level II).
Touch Interventions
Moderate-strength evidence exists that educating parents of premature infants in touch interventions can increase infants’ cognitive development. Touch interventions include kangaroo care (KC; Feldman et al., 2014, Level I) and massage (Abdallah et al., 2013, Level II).
Other Interventions
Low strength of evidence (because of nonsignificant findings) addresses the use of technology to enhance cognitive or literacy skills among young children. The Training Attention and Learning Initiative, a computer program focused on EF (Kirk et al., 2016, 2017, both Level I), and a computer training program emphasizing nonverbal reasoning (Bergman Nutley et al., 2011, Level I) did not result in statistically significant improvements in cognitive skills. Baby media that promised to teach toddlers to read were not effective (Neuman et al., 2014, Level I).
Theme 4: Interventions Implemented by a Preschool Team
Early Literacy Programs
There is strong evidence (8 Level I RCTs, 6 Level II studies, 2 Level III studies) that interventions conducted in preschools were effective in increasing literacy, working memory, and cognitive functions in young children. Two Level I studies found that young children who were at risk for learning delays significantly increased early literacy skills through emergent literacy interventions, which had a positive impact on writing and reading skills (Bailet et al., 2013; Sheridan et al., 2011). Specific curricula such as the Read It Again program significantly improved print knowledge, literacy print measures, and uppercase letter naming and word awareness (Hilbert & Eis, 2014, Level II; Justice et al., 2010, Level II; Schryer et al., 2015, Level II). Another program, Research-Based Developmentally Informed (REDI), significantly increased the developmental trajectories for learning and attention in preschoolers from low-income families (Nix et al., 2013, Level I), and providing intensive literacy activities (e.g., identify letters and sounds) to low-income preschoolers significantly increased print, letter, and letter-sound knowledge (Lonigan & Phillips, 2016, Level I). Occupational therapy practitioners working in schools are members of educational teams, including literacy teams and multitiered systems of support. They collaborate with educators and provide evidence-based interventions for children with and without educational or medical disabilities, based on their local and state education initiatives and regulatory requirements.
Reading Books
The use of specific daily activities focused on working memory and cognitive flexibility resulted in statistically significant improvements in these areas (Röthlisberger et al., 2011, Level I). Joint interactive storybook interventions also improved literacy skills (e.g., print concepts) over 2 mo (Vaknin-Nusbaum & Nevo, 2017, Level II). Both paper and ebooks significantly increased preschoolers’ ability to name letters, but the paper book was more effective (Willoughby et al., 2015, Level II).
Moderate-strength evidence exists for interventions that were used with preschoolers with diagnosed conditions. Preschoolers with developmental disabilities had statistically significant increases in literacy skills after a summer of the Kids in Transition to School program (an intensive summer school readiness program; Pears et al., 2016, Level I). After 45 wk of the Early Reading Program (e.g., shared reading with teachers and reading at home), preschoolers with DS had statistically significant improvements in literacy skills (Colozzo et al., 2016, Level III).
Other Interventions
Low strength of evidence exists for other interventions because of the limited number of studies, the lack of significant findings, or both. Preschoolers who were active for 30 min demonstrated statistically significant improvements in sustained attention (Palmer et al., 2013, Level III). Use of the Responsive Early Childhood Curriculum (RECC) and RECC plus social–emotional activities was not effective in changing cognitive scores in preschoolers (Landry et al., 2014, Level I). A mindfulness-based kindness curriculum with an emphasis on self-regulatory skills and prosocial behavior did not increase cognitive functions in preschoolers (Flook et al., 2015, Level I). Computer-based working-memory training was effective for memory and learning at 7-mo follow-up (Grunewaldt et al., 2016, Level II).
Moving Research Into Practice
This review of interventions to enhance cognitive development expanded on a previous SR (Frolek Clark & Schlabach, 2013) by adding pre-academic skills (e.g., learning, early literacy skills) because occupational therapy practitioners collaborate with early childhood teachers in this area. This review addresses only interventions within the scope of occupational therapy and offers strong evidence in support of occupational therapy with young children to enhance cognitive development and literacy skills in home, community, hospital, and educational settings.
Occupational therapy practitioners should implement interventions that include EI services (clinic or home-based) with parents using home programs; group interventions such as the Cognitive–Functional intervention; reading to infants, toddlers, and preschoolers; and specific training in cognitive skills and EF for preschoolers. Movement increased attention and should be incorporated before preacademic or focused tasks. Early literacy activities (e.g., learning letter names and sounds, writing letters) support at-risk preschoolers from low-SES backgrounds or with developmental delays. Practitioners should implement these activities and educate parents and other caregivers, child care providers, and teachers about the evidence to enhance cognitive and literacy skills. Practitioners understand the primary stages of literacy that occur at this age (e.g., emergent literacy as the child begins to use words, make requests, and recognize symbols and print; early literacy as the child identifies letters and sounds and uses invented spelling), and they recognize the vital link between functional literacy (e.g., understanding common written materials needed to carry out daily life skills) and the child’s current and future occupational performance. Ongoing research activities should include larger samples in multiple sites.
Case Vignette: Diego
Diego is a boy age 4.5 yr with ADHD who attends an ECSE preschool program and was referred by his teacher for an occupational therapy evaluation. While gathering the occupational profile from the parent and teacher, the occupational therapist learns that Diego achieved developmental milestones on time, cannot write his name, is unable to identify any letters or letter sounds (whereas peers can complete these tasks), and runs around during circle time rather than remaining seated with peers. His interactions with peers are minimal, and Diego often hits them to gain a toy or object from them. He refuses to complete most self-care activities. On the basis of the occupations identified as concerns, observations and various assessment methods are used to identify supports of and barriers to these occupations (e.g., play, learning, self-care, movement). Diego’s performance is observed during his preschool routines. His strengths and needs are identified as follows:
Strengths: Diego responds to adults’ verbal requests, demonstrates interest in books, initiates self-eating, sits for 30–45 s, and follows some simple routines.
Needs: Diego does not initiate or sustain peer interaction, play appropriately with objects, recognize shapes or letters, or imitate the prewriting strokes (e.g., circle, lines) needed for drawing or writing. He sits for less than a minute, so he runs around the room before classroom work is finished. Successful use of tools (pencils, crayons) during preschool classroom work requires adult physical assistance.
Using evidence-based interventions, the parent, preschool teacher, and school occupational therapist discuss occupational therapy services to work with Diego and agree to implement the following strategies to enhance his occupational performance:
With the provision of active movement breaks throughout the day, Diego will attend to and complete classroom activities for 15 min (Palmer et al., 2013, Level III).
During recess and free time, Diego will play with peers and use acceptable methods to gain access to toys. The occupational therapist will educate the family and preschool teacher on effective cognitive strategies to enhance eye–hand coordination, balance, listening skills, attention, inhibition, visual focusing, and sensory awareness (Tamm & Nakonezny, 2015, Level I; Tamm et al., 2014, Level III).
Environmental modification: Uppercase alphabet or shape (math) puzzles, books, and other materials will be used in school and at home to enhance imitation and literacy skills and increase Diego’s awareness of letters and shapes to prepare him for kindergarten and literacy activities (Bailet et al., 2013; Sheridan et al., 2011; both Level I).
Home program: The occupational therapist will provide activities that the parent can implement to enhance Diego’s cognitive and literacy skills, including reading to Diego (Pillinger & Wood, 2014, Level I; Pratt et al., 2015, Level I; Vaknin-Nusbaum & Nevo, 2017, Level II) and playing with him 10 min per day (Tachibana et al., 2012, Level I).
After 4 wk, the following progress was observed:
At preschool, Diego is now remaining in circle time for 4–5 min and has positively interacted with peers during recess twice in the past 2 days.
At home, he is now independently sitting with books or simple puzzles for 8 min (if he is not distracted).
Interventions Supporting Mental Health and Positive Behavior
Some risk factors known to influence mental health and behavior outcomes for children include trauma experience, preterm birth, and developmental disorders (Bul & van Baar, 2012; Stronach et al., 2013). In the United States, 1 in 10 infants is born preterm (CDC, 2018); 1 in 6 children has a developmental, mental health, or behavioral disorder diagnosed in early childhood (CDC, 2019); and at least 1 in 7 children experiences maltreatment in the form of abuse or neglect (Fortson et al., 2016). Developmental and life outcomes are worse for children who have experienced trauma, preterm birth, and developmental delays and who are also affected by disparities associated with poverty or being a racial or ethnic minority (Stronach et al., 2013). Therefore, the provision of EI to combat the impact of these risk factors on development is imperative.
For clients in early childhood, occupational therapy practitioners have a broad scope of practice and are important members of the team addressing mental health and positive behavior. The SR question was, “What is the evidence for the effectiveness of interventions within the scope of occupational therapy practice to improve mental health and positive behavior for children ages 0–5 yr and their families?” (Kingsley et al., 2020). Forty articles met the inclusion criteria—28 Level I studies, 7 Level II studies, and 5 Level III studies (Table 6). The articles were organized into three themes: (1) touch-based interventions, (2) Parent–Child Interaction Therapy (PCIT), and (3) instruction-based interventions.
Evidence for Interventions Supporting Mental Health and Positive Behavior
Note. N = 40. RCT = randomized controlled trial; SR = systematic review.
Theme 1: Touch-Based Interventions
In this theme were 9 articles describing 5 Level I studies, 2 Level II studies, and 2 Level III studies. Authors explored the efficacy of touch-based interventions, such as KC, skin-to-skin, or massage. Outcomes examined include attachment, child behavior, parenting behavior, parental stress, maternal depression, and infant self-regulation.
Kangaroo Care and Skin-to-Skin
Moderate-strength evidence in 1 Level I, 2 Level II, and 2 Level III studies, all with high risk of bias, supports the use of KC and skin-to-skin. Across several studies, KC and skin-to-skin were statistically effective interventions to increase maternal–infant attachment (Ahn et al., 2010, Level II; Cho et al., 2016, Level III; Feldman et al., 2014, Level II). Researchers investigated a range of dosages, and effectiveness was found with as few as three 30-min skin-to-skin sessions for attachment (Cho et al., 2016). Mothers who spent at least 10 hr in the skin-to-skin position across the 3-wk study period experienced a significant reduction in depression compared with mothers in the control group (Ahn et al., 2010). The incorporation of mothers singing lullabies during 60 min of KC had a statistically significant positive impact on maternal anxiety (Lai et al., 2006, Level I). In their Level III study, Srinath et al. (2016) explored the difference between a 60-min KC session provided by the infant’s mother and one provided by the infant’s father and found no statistically significant differences in stress or physiological data, suggesting that KC provided by the father is similarly effective as KC provided by the mother.
Massage
Four Level I studies ranging from low to moderate risk of bias provide strong evidence for the effectiveness of massage. The studies examined a variety of manualized massage approaches including Baby’s First Massage, Qigong massage, and author-designed protocols. Three studies yielded strong evidence supporting the use of massage to improve infants’ self-regulation (Bennett et al., 2013; Juneau et al., 2015; Silva et al., 2011). In 2 studies, the use of massage was found to reduce parental stress levels, with a range of small to large effect sizes (Oswalt & Biasini, 2011; Silva et al., 2011).
In addition, Silva et al. (2011) found that Qigong massage significantly improved behavior in preschoolers with ASD after 4 mo of intervention. After 10 wk of Baby’s First Massage, mothers diagnosed with HIV reported a significant reduction in their level of depression (Oswalt & Biasini, 2011).
Theme 2: Parent–Child Interaction Therapy
Two Level I, 1 Level II, and 1 Level III studies, all with high risk of bias, examined PCIT. Moderate-strength evidence was found for the effectiveness of PCIT to support behavior. PCIT is a manualized intervention with facilitation and support of parent–child interaction via one-way mirrors and parents being advised via headsets (Ros et al., 2016, Level I). Dosages of PCIT varied greatly across studies, with effectiveness documented after as little as 1 hr/wk for 4 mo and as long as 60–90 min/wk for 2 yr.
All of the studies in this theme found a statistically significant decrease in child externalized and challenging behaviors postintervention as measured by parent report (Bagner et al., 2016, Level II; Fung et al., 2014, Level III; Rodríguez et al., 2014, Level I; Ros et al., 2016, Level I). Two studies provided low strength of evidence for improved parental discipline, reduced negative parenting behaviors, and increased positive parenting behaviors: One study found no statistically significant results (Bagner et al., 2016, Level II), and another found significant results with medium to large effect sizes (Fung et al., 2014, Level III). Studies that examined PCIT’s impact on parental stress levels resulted in low strength of evidence. Bagner et al. (2016) found no statistically significant effects on parental stress levels as measured by the Parenting Stress Index. However, Ros et al. (2016) found that parents reported a statistically significant reduction in stress when they had higher follow-through on incorporating PCIT strategies assigned as homework by the interventionists.
Theme 3: Instruction-Based Interventions
Thirty-three articles contribute to the evidence under this theme, with approaches including parent training, group-based parent training, and teacher training.
Parent Training: Parenting Behavior
Four Level I studies, 1 Level II study, and 1 Level III study examined the use of parent training to improve outcomes related to parenting behaviors. There is strong evidence supporting parent training to improve parenting behavior.
Consistent parent training meetings over a 12-mo period resulted in statistically significant improvements in parent responsiveness and parent–child dyadic behavior (Solomon et al., 2014; Wu et al., 2014, both Level I). After participating in an 11-wk program, parents were significantly better able to respond to children’s externalizing and internalizing behaviors (Kierfeld et al., 2013, Level I). Incredible Years parent training (evidence-based programming designed to prevent and treat behavior problems and promote social and emotional competence) implemented for 10 wk resulted in statistically significant increases in the use of positive parenting strategies and consistent use of discipline (McMenamy et al., 2011, Level III; Perrin et al., 2014, Level I). One Level II study examining dosage and delivery (Kusanagi et al., 2011) found that the less intensive intervention group, who received 2 home visits, showed statistically significant improvements in infant state regulation and cue reading compared with the intensive group, who received pre-NICU discharge intervention and weekly sessions.
Parent Training: Child Behavior
Nine studies (8 Level I, 1 Level III) examined the impact of parent training on child behavior. The majority of articles had high risk of bias and yielded moderate-strength evidence supporting parent training to affect child behavioral outcomes. Several studies looked at manualized programs such as the Incredible Years and MIT programs and found significantly decreased child aggression, increased compliance, and increased socialization (McMenamy et al., 2011, Level III; Nordhov et al., 2012, Level I; Wetherby et al., 2014, Level I). However, 3 additional Level I studies found no statistically significant impact of parent training on child behavior (Homem et al., 2014; Spieker et al., 2012; Wu et al., 2014).
Two Level I studies examined the use of self-help books with weekly phone consultations and found statistically significant improvements in children’s internalizing and externalizing behavior (Ise et al., 2015; Kierfeld et al., 2013). An SR analyzed 17 studies with high risk of bias and found no statistical evidence of improvement when parent-mediated interventions were used to support a variety of child and parent outcomes, including child initiation in parent–child interactions, language, adaptive behavior, or parenting stress (Oono et al., 2013, Level I).
Parent Training: Parental Mental Health
Two Level I and 1 Level II studies provide moderate-strength evidence for parent training to improve parental mental health. Parents who received a home-based PLAY Project intervention reported significantly lower depression scores than control group parents (Solomon et al., 2014, Level I). Providing 60- to 90-min training sessions for pregnant women regarding attachment behaviors did not statistically significantly improve anxiety compared with control participants (Akbarzadeh et al., 2016, Level I). Providing clinic-based training to mother–infant dyads that focused on attachment had a moderate effect on maternal stress (Komoto et al., 2015, Level II).
Parent Training: Child Mental Health
As a result of limited amounts of research and inconsistent findings, 2 studies yielded low strength of evidence that parent training is an effective approach to improving child mental health outcomes. After participation in 11 1-hr sessions of the MIT program, infants were observed to have more positive mood (Ravn et al., 2011, Level I); however, the change was not statistically significant. When analyzing the outcomes of attachment training, Komoto et al. (2015, Level II) found no statistically significant differences in child stress.
Parent Training: Maternal–Infant Attachment
Strong evidence indicates that the use of a parent training approach is effective when targeting maternal–infant attachment, with 5 Level I studies and 1 Level II study with low risk of bias examining this outcome. Several studies found statistically significant improvements in mothers’ sensitivity to infant cues after parent training programs (Evans et al., 2014, Level I; Komoto et al., 2015, Level II; Ravn et al., 2011, Level I; Spieker et al., 2012, Level I). Dosage across studies varied from 7.5 to 11 hr per week. The MIT program had some inconsistent results, with 1 Level I study (Ravn et al., 2011) showing improved mother–infant interactions after 11 hr of intervention and another Level I study (Kynø et al., 2012) showing no statistically significant difference on measures of attachment between the intervention and control groups after 10 hr of MIT.
Parent Training: Infant Sleep
Two Level I studies that examined the effectiveness of parent training as a means to address child sleep problems provide low strength of evidence because of inconsistent results. Douglas and Hill (2013) found behavioral interventions with infants younger than age 6 mo did not effectively prevent sleep and behavior problems in later childhood. An RCT examined the impact of parent training on infant sleep and found statistically significant improvement in sleep latency (Gradisar et al., 2016). These 2 studies used very different models of intervention but shared a common delivery via parent training. It is not possible to reach a conclusion on effectiveness at this time.
Group-Based Parent Training
Low strength of evidence (because of risk of bias and inconsistent findings) was found for the use of a group format to train parents. This subtheme included 3 Level I studies and 1 Level II study. In their Level I SR, Barlow et al. (2016) found moderate-strength evidence to support group-based parent training to reduce emotional and behavior problems in children younger than age 3 yr. In another Level I study, parents completing 14 wk of group parenting classes showed statistically significant improvements in parenting behavior and a reduction in callous–unemotional behaviors (Elizur et al., 2017). A specific program to train parents in socialization strategies for their preschool children with hyperactivity resulted in significantly decreased disruptive and hyperactive–impulsive behaviors and improved attention; however, this Level I study has a high risk of bias and should be interpreted with caution (Herbert et al., 2013). Finally, a Level II study found that group-based parent training had no significant effect on parenting self-competence or stress (Keen et al., 2010).
Preschool Teacher Training
Four studies (2 Level I, 1 Level II, and 1 Level III) examined teacher training and yielded moderate-strength evidence for improving child behavioral outcomes. In their Level III study examining the effectiveness of training teachers to use Positive Behavioral Interventions and Supports (PBIS), Stanton-Chapman et al. (2016) found that children showed statistically significant improvements in their social skills and a reduction in problem behaviors. Use of the Social–Emotional Prevention program with high-risk preschool children resulted in statistically significant levels of improved behaviors and social competence postintervention (Ştefan, 2012, Level II).
The Learning Experiences–An Alternative Program for Preschoolers and Parents (LEAP) program is a comprehensive individualized and evidence-based program for educating young children with ASD in a public school setting (Strain & Bovey, 2011, Level I). It encompasses inclusion, high-quality classrooms, peer-mediated social skills, and training for families and draws from many approaches, ranging from errorless learning to positive behavioral support. Using the LEAP program with a 2-yr training and coaching model for teachers yielded statistically significant improvements in social behavior and a reduction in problem behaviors for children with ASD (Strain & Bovey, 2011). In another Level I study, Vancraeyveldt et al. (2015) found a statistically significant reduction in teacher–child conflict, improved child conduct, and a reduction in hyperactivity and inattention in children after 15 wk of teacher training.
Moving Research Into Practice
The evidence for effective interventions promoting mental health and positive behavioral outcomes in early childhood covers a broad variety of interventions. The use of touch-based interventions influences attachment, self-regulation, and maternal mental health. PCIT is an effective intervention for child behavioral outcomes, but it should be used with caution for parental outcomes. However, parent training in a variety of other approaches was not significantly effective in influencing the behavior of young children but had a positive impact on maternal mental health. Training teachers in specific interventions and approaches had a positive influence on child behavioral outcomes.
When making recommendations, occupational therapy providers need to incorporate their practice-based experience along with research evidence to make individualized clinical recommendations that best meet the needs of the children and families they serve. Note that a large gap exists in the literature with regard to fathers as caregivers, and occupational therapists should exercise judgment when applying this research to fathers.
Case Vignette: Kai
Kai was born very preterm at 32 wk, with exposure to methamphetamines and alcohol. The Department of Family and Child Services placed her in protective custody shortly after birth. After discharge from the NICU at the adjusted age of 2 mo, Kai was placed with her foster parents.
According to her results on the Bayley Scales of Infant Development, 4th Edition (Bayley & Aylward, 2019), Kai is delayed across all areas of development. Synthesizing multiple sources of assessment data, the EI occupational therapist constructs an occupational profile for Kai and her family and uses the results to inform the intervention plan. On the basis of the therapist’s knowledge of evidence-based practice, the therapist recommends daily skin-to-skin sessions with both caregivers to facilitate caregiver–infant attachment and Baby’s First Massage protocols to facilitate state regulation for Kai and stress reduction for caregivers (Oswalt & Biasini, 2011, Level I).
At age 2 yr, Kai is reunited with her birth mother. Occupational therapy services are still indicated, and the occupational therapist recommends parenting support classes to increase competencies in responding to child behavior and positive parenting behaviors because of high risk factors (Solomon et al., 2014; Wu et al., 2014, both Level I). Since moving in with her mother, Kai has experienced a higher frequency of externalized behaviors toward her mother, including hitting, hair pulling, and yelling. The treating occupational therapy practitioner suggests PCIT to the social worker overseeing Kai’s case as an effective strategy to address Kai’s behavior (Bagner et al., 2016, Level II; Fung et al., 2014, Level III; Rodríguez et al., 2014, Level I; Ros et al., 2016, Level I). In preparation for the transition to preschool, the team recommends a parent training program along with school readiness training and placement in an Early Head Start program with teachers trained in using PBIS (Stanton-Chapman et al., 2016, Level III).
Interventions Supporting Motor Development
Motor skills are essential to a child’s ability to participate in play, self-care, social interactions, and education (Case-Smith et al., 2013). During the early childhood years, children are engaging in occupations such as learning, play, eating, moving, dressing, and social interaction. These occupations are supported by fine motor movements (e.g., reach, grasp, manipulate objects, use tools), large motor movements (e.g., sit up, pull to stand, walk, run), and visual–motor skills (e.g., coordinating eyes and hands).
When children’s motor skills are at risk or delayed, occupational therapy practitioners use interventions to promote development of those skills. Young children with certain conditions, including prematurity and LBW, CP, ASD, and muscle disorders, have a higher risk of developmental delays. They may receive occupational therapy services in hospital, home, and community (preschool, day care) settings to minimize delays; develop motor coordination and strength; and support the family’s, preschool teacher’s, or day care provider’s ability to enhance their occupational performance and participation.
The SR question was, “What is the evidence for the effectiveness of interventions within the scope of occupational therapy practice to promote motor development and prevent further delay for children ages 0–5 yr?” (Tanner et al., 2020). Fifty-six articles met the criteria for inclusion in the SR (Table 7). Three intervention themes emerged: (1) EI (0–3 yr), (2) interventions for preschool children (3–5 yr), and (3) interventions for children with or at risk for CP (0–5 yr).
Evidence for Interventions Supporting Motor Development
Note. N = 56. RCT = randomized controlled trial; SR = systematic review.
Theme 1: EI for Children Ages 0–3 Years
The first theme included 19 studies (13 Level I [2 SRs, 1 including a meta-analysis, and 11 RCTs], 5 Level II, 1 Level III) that explored the efficacy of EI (i.e., interventions for children younger than age 3 yr). Subthemes derived from the review of the literature include EI for premature infants; parent-implemented home-based interventions; combined clinic and home-based interventions; massage; CareToy; and other interventions.
EI for Premature Infants
Three Level I studies (2 SRs and 1 RCT) fell under this subtheme. On the basis of the number, level, and quality of studies, the evidence for EI is strong. An SR with a meta-analysis showed that EI programs can significantly improve short-term motor development. Park et al.’s (2014) SR found a small, significant effect (d = 0.118) of movement-related performance for premature or LBW infants participating in EI programs. An SR of premature infants who received EI after hospital discharge found a small, significant short-term effect on motor skills compared with standard care (Spittle et al., 2012). Evidence from an RCT showed that NIDCAP improved motor function for preterm infants with severe intrauterine growth restriction at 2 wk corrected age, but results at 9-mo follow-up were not significant (Als et al., 2011).
Parent-Implemented Home-Based Interventions
Seven Level I RCTs in which parents were trained to implement home-based programming provide moderate-strength evidence because of inconsistent results. The IBAIP, a preventive neurobehavioral intervention that supports infant–family interactions and infants’ self-regulatory competence, demonstrated a statistically significant positive effect on long-term motor scores of children in the intervention group compared with those in the control group at follow-up at age 5.5 yr (Van Hus et al., 2016), especially for infants with bronchopulmonary dysplasia. Dusing et al. (2015) used an intervention that emphasized engaging families in their premature infant’s development during transitions from NICU to home and the community and found a large effect size (d = 1.29) by 3 mo adjusted age. A study of infants who were resuscitated at birth indicated that a parent-implemented EI program was significantly more effective at age 3 yr than a home visiting program (Carlo et al., 2013).
Four RCT studies did not find these specific programs effective. In Taiwan, Wu et al. (2014) found that infants who received home-based intervention programs did not demonstrate statistically significant positive changes by age 36 mo compared with the control group (who received standard care), but the infants receiving clinic-based intervention did. An RBEI program designed to enhance children’s participation in family routines and the current environment with goals selected by the family was provided to preterm children for 6 mo and compared with 6 mo of traditional home visit interventions (using a developmental curriculum in the home setting). Results indicated no significant between-groups differences (Hwang et al., 2013). A long-term study (Nordhov et al., 2010) using the MIT program to promote parent–infant interactions for LBW infants found no significant difference between the intervention and control groups at ages 3 or 5 yr. A home-based parent-implemented EI model did not demonstrate any significant between-groups differences in developing countries (Wallander, Bann, et al., 2014).
Combined Clinic and Home-Based Interventions
Moderate-strength evidence was found that combined clinic and home programming can enhance motor skills. One Level I RCT (Tang et al., 2011) found significant improvements in fine and large motor performance among children who received clinic-based therapy and home programming compared with those who received only clinic-based therapy.
Massage
Moderate-strength evidence indicates that Qigong massage may improve the large motor skills of children with CP or DS, but the evidence does not apply to children with prematurity. A Level I RCT (Silva et al., 2012) found a statistically significant increase in motor performance among children with CP or DS whose parent provided Qigong massage. A Level II study of premature infants (Abdallah et al., 2013) did not find any statistically significant changes after 10 sessions of parent-administered massage.
CareToy
Two studies of the CareToy, a smart infant gym, found moderate-strength evidence for motor skill improvement among preterm infants. A Level II study by Sgandurra et al. (2016) of 6 preterm infants found statistically significant improvements in motor scores. They followed this study with a Level I RCT (Sgandurra et al., 2017) of 19 preterm infants who demonstrated statistically significant improvements in motor scores compared with the control group after a 4-wk program.
Other Interventions
Several interventions have low strength of evidence because of the limited number of studies addressing them. Power mobility is often used to enhance children’s mobility; however, the strength of evidence for it is low. A Level I RCT found that children ages 14–30 mo improved their functional mobility skills (e.g., running, jumping) and reduced their need for caregiver assistance but did not specifically improve their motor skills (Jones et al., 2012). Although 1 study found that infants with DS whose caretakers initiated tummy time early (before age 11 wk) demonstrated statistically significant improvements in test scores (Wentz, 2017, Level II), the evidence that tummy time improves specific motor function in infants is of low strength. Another study indicated that weekly infant swimming lessons resulted in no between-groups difference (Dias et al., 2013, Level II). Children receiving a sensory-enhanced center-based EI program demonstrated statistically significant improvements in fine and large motor performance after 3–9 mo of enrollment (Blanche et al., 2016, Level III).
Theme 2: Interventions for Preschool Children Ages 3–5 Years
Nine studies (4 Level I, 3 Level II, and 2 Level III) explored the efficacy of interventions for preschoolers. Subthemes include video games, programs emphasizing motor skills, movement, and sensory-based interventions.
Video Games
Two Level I RCTs and 1 Level III study provide strong evidence that video games can be used to improve large motor skills, but not enough evidence is available to support video game use to improve fine motor and visual–motor skills. An RCT (Hsieh et al., 2016, Level I) found a statistically significant increase in motor test scores after an 8-wk program. Another Level I RCT (Salem et al., 2012) found that a low-cost virtual reality game resulted in statistically significant improvements on two tasks that are critical foundations for occupational performance (i.e., one-leg balance and grip strength) compared with traditional therapy. Hsieh et al. (2015, Level III) found that children with developmental disabilities had statistically significant improvements in motor, visual–motor, and fine motor scores after intervention with an adaptive video game using a joystick.
Programs Emphasizing Motor Skills
Moderate-strength evidence (1 Level I, 2 Level II studies) exists that preschool programs can improve motor skills. An RCT of kindergarteners who received fine motor interventions from an occupational therapist (direct and consultative services) demonstrated statistically significant positive results compared with a control group (Ohl et al., 2013, Level I). A Level II study (Lust & Donica, 2011) using three 20-min sessions/wk of Handwriting Without Tears–Get Set for School for 3 mo found that children age 4 made statistically significant improvements on several fine motor and literacy measures. Another study (Reimer et al., 2011, Level II) implemented a biweekly program that used magnifier training (e.g., using a magnifier while following trails printed on paper) for children with visual impairments. After 6 wk of this training, the results indicated significant improvement on various fine motor items.
Movement
Moderate-strength evidence (1 Level I RCT, 1 Level III study) indicates that physical movement can improve preschoolers’ motor skills. In an RCT, Bellows et al. (2013, Level I) provided the Mighty Moves program, which focuses on stability, locomotor, and manipulation skills, for 4 days/wk over 18 wk. Motor score results for the treatment group improved significantly compared with those for the control group. Children who received three 15-min breaks per day for 6 mo with physical movement circuit activities demonstrated statistically significant improvements on the 12-m run and standing long jump (Monsalves-Alvarez et al., 2015, Level III).
Sensory-Based Interventions
The evidence that sensory-based therapy can improve large motor skills in preschoolers is of low strength. A study of children with ASD (Iwanaga et al., 2014, Level II) found that receiving sensory integration therapy (the study was conducted before the establishment of criteria for Ayres Sensory Integration® therapy) weekly for 8–10 mo significantly improved their coordination scores (large, fine, and oral–motor) and complex index scores (sensory–motor and cognition).
Theme 3: Interventions for Children With or At Risk for CP Ages 0–5 Years
Twenty-five Level I (3 SRs, 22 RCTs) and 3 Level III studies make up this theme. There are five subthemes: (1) EI programs, (2) constraint-induced movement therapy (CIMT) and bimanual intensive therapy (BIT), (3) child- and context-focused interventions, (4) hippotherapy, and (5) other interventions.
EI Programs
Strong evidence indicates that EI programs can improve motor development in children ages 0–3 yr with or at risk for CP. Six Level I studies (2 SRs, 4 RCTs) found significant improvements as the result of various interventions. An SR of EI for children at high risk for CP found a lack of high-quality studies (Hadders-Algra et al., 2017, Level I). However, this SR found that neurodevelopmental treatment with therapy at least 5 times a week provided significantly better outcomes. An earlier SR on the effectiveness of motor interventions for children with CP (Morgan, Darrah, et al., 2016, Level I) found that child-initiated movement, task-specific training, and environmental modifications had the largest effect sizes and higher quality evidence. Two RCTs found that the Goals–Activity–Motor Enrichment program resulted in statistically significant motor improvements over standard care at 12 mo (Morgan et al., 2015; Morgan, Novak, et al., 2013; both Level I). Two other Level I RCTs compared the Coping and Caring program for infants, a family-centered coaching approach, with standard care (Dirks et al., 2016) or with traditional physical therapy (Blauw-Hospers et al., 2011). Dirks et al. (2016) found significantly increased functional mobility in intervention group children at 18 mo compared with control group children (standard care), and Blauw-Hospers et al. (2011) found no difference between groups in developmental outcomes at 3, 6, and 18 mo adjusted age.
Constraint-Induced Movement Therapy and Bimanual Intensive Therapy
On the basis of 13 Level I RCTs and 1 Level III study, strong evidence exists for CIMT and BIT to improve motor skills in children ages 0–5 yr with unilateral CP. Two RCTs compared CIMT (3–6 hr per day) with typical occupational therapy (once a week) and found statistically significant increases in functional skills and independence among preschoolers (de Brito Brandão et al., 2010; Taub et al., 2011; both Level I). A multisite RCT found that children who received 3 or 6 hr per day of CIMT for 21 days had similar motor improvements, but both dosages of CIMT were more effective than traditional therapy (DeLuca et al., 2012, Level I). A follow-up study found children receiving CIMT maintained their results after 6 mo (Case-Smith et al., 2012, Level I). A pilot study with infants ages 6–18 mo with unilateral CP who received CIMT also showed statistically significant improvement in fine and large motor skills, with gains maintained at 1-mo follow-up (Lowes et al., 2014, Level III).
Three Level I RCTs focused on motor learning principles and matched dosages of CIMT and BIT. Although the CIMT and BIT groups both had increases in performance, no significant between-groups differences in motor outcomes were found (Facchin et al., 2011; Gelkop et al., 2015; Hoare et al., 2013).
Studies also found that CIMT and BIT were effective in home or group settings. Two Level I RCTs found significant improvements in motor outcomes for children with unilateral CP using modified CIMT (6 wk) and BIT (2 wk) during a group intervention at a camp (Aarts et al., 2010, 2011, both Level I). Two Level I RCTs examined families’ ability to conduct a modified in-home version of CIMT. The first found a significant improvement in function on the impaired side (Eliasson et al., 2011). The second (Al-Oraibi & Eliasson, 2011) compared children who received 1 hr of CIMT weekly from an occupational therapist and parents trained to provide 2 hr of in-home therapy daily with children who received neurodevelopmental treatment, which was consistent with the findings from Novak et al. (2013, SR). CIMT was found to significantly improve scores on the Assisting Hand Assessment (AHA; Krumlinde-Sundholm et al., 2007). Wallen et al. (2011, Level I) studied modified CIMT and traditional occupational therapy (no constraints) and found no differences. A study comparing traditional occupational therapy and CIMT with or without electrical stimulation did not find any differences in outcomes (Xu et al., 2012, Level I).
Child- and Context-Focused Interventions
On the basis of 2 Level I RCTs, strong evidence exists that child- and context-focused interventions improve motor skills in children with CP. One Level I RCT (Law et al., 2011) focused on two interventions: environmental barriers (e.g., interventions focused on the context) and remediating improvements (e.g., therapy focused on the child’s body function and structure). The researchers found a significant increase in functional motor skills, no decrease in range of motion, and a decrease in assistance needed from caregivers in both groups. A second Level I RCT (Kruijsen-Terpstra et al., 2016) compared three methods to enhance preschool children’s activities and participation: child focused (e.g., focus on the child’s abilities by altering components of body function and structure), context focused (e.g., focus on changing task constraints, environmental constraints, or both), and standard occupational therapy and physical therapy services (e.g., focus on impairments). The researchers found that all groups had a similarly significant increase in mobility and large motor skills, indicating these three methods were equally effective for preschoolers. Harbourne et al. (2010, Level I) did not find an interaction effect when comparing home programs with perceptual–motor programs to address postural control in infants with CP.
Hippotherapy
Moderate-strength evidence indicates that, when combined with standard therapy, hippotherapy improves balance and large motor skills in children with CP. One RCT found that the group who received 30 min of hippotherapy twice a week for 8 wk in addition to therapy had statistically significant improvements in motor skills (Kwon et al., 2015, Level I).
Other Interventions
The evidence that visual–perceptual training improves motor and functional skills in children with CP is of low strength. Cho et al. (2015, Level III) found significant improvements in two visual–motor measures and ADLs after 24 sessions (three 30-min sessions weekly for 8 wk). Low strength of evidence was found that goal-directed functional therapy can increase gross motor skills in preschoolers with CP. A study conducted at five habilitation centers for 12 wk found significant improvements in motor skills (Löwing et al., 2010, Level III). One Level I RCT (Bailes et al., 2011) provided low strength of evidence for wearing a TheraSuit® (i.e., a garment that uses bungee cords to provide resistance during movement) to improve motor skills. Children with CP who wore a TheraSuit and participated in an intensive therapy program did not demonstrate improved motor skills compared with the control group.
Moving Research Into Practice
Occupational therapy is a primary service for young children with or at risk for motor delays, including those with CP and developmental delays. Compared with the previous SR addressing this area (Case-Smith et al., 2013), the recent SR (Tanner et al., 2020) found a notable increase in interventions implemented by occupational therapists. The current SR provides practitioners with strong evidence on interventions within their scope of practice. For example, the evidence that CIMT and BIT improve motor skills in children with unilateral CP is strong (Aarts et al., 2010, 2011; de Brito Brandão et al., 2010; DeLuca et al., 2012; Taub et al., 2011). In addition, client- and context-centered interventions were both effective for children with CP. The evidence for other interventions used by occupational therapy practitioners, including Qigong massage, EI, training parents in home-based activities, using handwriting programs to increase fine motor skills, and enhancing gross motor skills with movement breaks and video games, is moderate. High-quality research is needed to investigate occupation-based interventions and outcomes in this area.
Case Vignette: Sella
Sella and her twin sister were born prematurely at 30 wk. Sella is 3 yr old and has a diagnosis of unilateral CP (right side) as a result of periventricular leukomalacia. The twins received EI until age 3 yr. The twins are now cared for in their home by their retired paternal grandparents (their grandmother was formerly a preschool teacher). Recently, the family physician talked with the family about an in-home version of CIMT and suggested that they contact an occupational therapist for an evaluation to determine whether this intervention is appropriate for Sella.
The outpatient occupational therapist interviewed the parent to construct the occupational profile and identify supports and barriers to Sella’s occupational performance. In addition to observing Sella during play, self-care, and movement, the therapist administered the AHA, Quality of Upper Extremities Skills Test (DeMatteo et al., 1992), and Pediatric Motor Activity Log (Taub et al., 2012). Sella had moderate right-hand function (e.g., grasping with whole hand, no isolated finger movements).
Because of Sella’s significant delays, the occupational therapist shared various CIMT intervention models with the parent, who preferred the 2-hr, 2-mo model (Eco–CIMT; Eliasson et al., 2011, Level I), which required the parent and grandparents to be trained to implement activities at home. The occupational therapist trained the family and supervised the home activities twice a month for 8 wk. The caregivers implemented the program with fidelity and were pleased that Sella’s ability to use her right hand and finger control during play and self-care improved during the 8 wk.
Interventions Supporting Activities of Daily Living, Rest, and Sleep
Occupational therapy practitioners frequently address clinical outcomes related to participation in ADLs and rest and sleep during early childhood. Children with feeding difficulties may engage in a variety of disruptive behaviors that interfere with mealtime routines. Parents of children with feeding and eating difficulties may resort to coaxing, bribing, and other counterproductive strategies to increase their child’s intake (Sharp et al., 2017). Toilet training can be a stressful time for families with young children. Children with developmental disorders are more likely to experience delays in independence with toileting (Rinald & Mirenda, 2012). Infants and young children with sleep issues often disrupt the sleep patterns of the entire family. Lack of sleep can lead to increased caregiver depression and likelihood of using physical discipline (Gradisar et al., 2016).
The SR question was, “What is the evidence for the effectiveness of interventions within the scope of occupational therapy practice to support ADLs, rest, and sleep for children ages 0–5 yr and their families?” (Gronski & Doherty, 2020). Forty articles were included in the SR (Table 8). The evidence included three main intervention themes: (1) feeding and eating, (2) toileting, and (3) rest and sleep. Specific intervention approaches include, but are not limited to, behavioral interventions, parent and caregiver training, and contextual interventions.
Evidence for Interventions to Support Activities of Daily Living, Rest, and Sleep
Note. N = 40. RCT = randomized controlled trial; SR = systematic review.
Feeding and Eating
Ten Level I, 1 Level II, and 3 Level III studies made up the 14 studies contributing to the evidence for interventions supporting feeding and eating. This theme included the following intervention subthemes: repeated exposure, nonnutritive suck, parent training, and tube feeding weaning.
Repeated Exposure
Five Level I studies with low to moderate risk of bias provide strong evidence to support repeated-exposure interventions. The interventions included repeated exposure to nonpreferred food items with or without behavioral reinforcement. A group receiving repeated exposure to vegetables paired with reinforcement had significantly fewer food refusals than repeated-exposure-only and control groups (Corsini et al., 2013). Children ages 2–4 yr had a statistically significant increase in their intake of a target vegetable with six exposures across 6 wk, but those with high food neophobia (an overwhelming fear of new foods) had significantly lower intake than those without neophobia (de Wild et al., 2017). In their 14-wk study, Holley et al. (2015) found that rewards for acceptance of a target vegetable yielded significantly higher ratings of the vegetable by children. The use of repeated exposure alone was found to significantly reduce consumption of three target vegetables in preschool children compared with a control group (O’Connell et al., 2012). Tangible rewards were more effective than social rewards in reinforcing consumption of the target vegetable (Remington et al., 2012).
Nonnutritive Suck
There is moderate-strength evidence that nonnutritive suck can affect intake volume during infant feedings. One Level I study and 1 Level II study with low and moderate risk of bias, respectively, contribute to this subtheme. Chorna et al. (2014, Level I) showed that use of recordings of the mother singing lullabies paired with nonnutritive suck on a pacifier for 15 min across 5 days yielded statistically significant increases in oral feeding rates and feedings per day. Hwang et al. (2010, Level II) demonstrated that oral stimulation paired with nonnutritive suck yielded an increased rate of intake during the first 5 min of feedings, but no statistically significant difference remained when analyzing the entirety of the feeding.
Parent Training
Moderate-strength evidence supports the use of parent training related to feeding outcomes. This subtheme included 2 Level I studies with low to moderate risk of bias and 3 Level III studies with moderate to high risk of bias. A study of a 16-wk manualized parent-training program on behavioral approaches to feeding for children with ASD found statistically significant improvements in children’s mealtime behavior but no differences in nutritional status (Johnson et al., 2015, Level III). Maestro et al. (2016, Level III) focused on improving the parent–child relationship 1 day per week at a therapeutic preschool and found that more than half of the participants with sensory food aversion or disorder of caregiver–infant reciprocity improved in regard to postponing food intake, selective and picky eating, and playing instead of eating. However, this study relied exclusively on parent report, provided only descriptive statistical analysis, and is susceptible to high risk of bias.
Sharp et al. (2014, Level I) found that parents self-reported lower levels of stress after 8 hr of parent training using behavioral strategies with their children diagnosed with ASD, but children showed no significant improvements in feeding behaviors or dietary variety. A Level III study (Sobko et al., 2017) found that parents who participated in 12 1-hr workshops demonstrated statistically significant improvements in behaviors supporting mealtime and children demonstrated a statistically significant improvement in picky eating and resistant mealtime behaviors. Wen et al. (2011, Level I) demonstrated that home visits twice during pregnancy and follow-up visits at 1, 3, 5, 9, and 12 mo significantly increased breastfeeding and decreased use of food as a reward for behavior.
Tube Feeding Weaning
Two Level I RCTs with low risk of bias examined two different interventions targeting weaning from tube feeding. An inpatient hunger provocation program was used to successfully wean 9 of 11 participants within a 3-wk period (Hartdorff et al., 2015). The use of a manualized behavioral intervention via a tablet significantly increased accepted bites and decreased mealtime disruptions after 14 meal blocks (40 min each) over 5 days compared with controls (Sharp et al., 2016). The interventions in this subtheme are too disparate to draw a conclusion about overall effectiveness.
Toileting
Six articles were included in this theme—2 Level I studies, 3 Level III studies, and 2 Level IV studies. Risk of bias ranged from low to moderate across articles. The toileting theme is divided into the following subthemes: caregiver education, punitive language, wetting alarm, and multidisciplinary approach in CP.
Caregiver Education
Three Level III studies and 1 Level IV study explored caregiver education to address toileting in children. The Level III studies all have a moderate to high risk of bias and few statistically significant findings, and therefore the evidence regarding this type of intervention is of low strength. A small Level IV study (Cicero & Pfadt, 2002) tracked 3 children with ASD participating in a teacher-led training program with elements of habit training and behavioral reinforcement for requesting to toilet and found a nonsignificant increase in toileting requests and fewer urination accidents. The use of an animated video, prompts to request toileting, and behavioral reinforcement for each step of the toileting routine resulted in a nonsignificant increase in in-toilet urination that was maintained at follow-up (Keen et al., 2007, Level III). In another Level III study (Law et al., 2016), a medical–behavioral program called Toilet School used group-based parent training and a child-focused behavioral intervention; children showed a statistically significant increase in bowel movements in the toilet, were more likely to assist with cleaning themselves, and were less likely to refuse toileting. A third Level III study (Rinald & Mirenda, 2012) found that four 2-hr parent workshops using a modified Rapid Toileting Training protocol with 6 families resulted in a nonsignificant increase in urination and defecation in the toilet.
Punitive Language
Low strength of evidence was found that avoiding punitive language may affect defecation-related toileting. An RCT with low risk of bias and no significant findings supports the removal of punitive language (Taubman et al., 2003, Level I). Among children ages 17–19 mo, using public toilet training guidelines, avoiding negative and punitive language for feces, and praising bowel movements in their diaper resulted in no significant difference in toileting refusal and hiding during bowel movements.
Wetting Alarm
Moderate-strength evidence supports the use of wetting alarms with children ages 18–30 mo. A Level I RCT with moderate risk of bias found that children who wore a daytime wetting alarm were significantly more likely to become toilet trained than children who wore a placebo alarm (Vermandel et al., 2009).
Multidisciplinary Approach in CP
Low strength of evidence addresses the use of a multidisciplinary approach for children with CP. The authors of 1 Level IV study (Millard et al., 2013) used a multidisciplinary medical intervention with 5 children ranging in age from 4 to 18 yr and found no statistically significant changes in independence in toileting, although scores on the WeeFIM II® improved.
Rest and Sleep
This theme includes 19 studies—14 Level I, 2 Level II, and 3 Level III. This theme is organized into the following subthemes: parent training for infants, parent training for young children, touch-based interventions, and positioning devices.
Parent Training for Infants
This subtheme includes 6 Level I studies, 2 Level II studies, and 1 Level III study with moderate risk of bias. Moderate-strength evidence supports parent training for sleep outcomes, but dosage seems particularly important. Studies that used 3 or more hours of training showed statistically significant effects. A study in which parents were trained in either gradual extinction of response to their infant’s cries at bedtime or bedtime fading in which the infants’ sleep window was gradually limited found statistically significant effect sizes on sleep latency compared with the control condition (Gradisar et al., 2016, Level I). The use of parent support providers and a 6-hr training on responding to infant cries and sleep interventions yielded a statistically significant reduction in infant night waking and time to settle the infant at night (Hauck et al., 2012, Level II). In a Level I study, Salisbury et al. (2012) found significant treatment effects for three parent-training sessions regarding potential causes of and responses to infant cries; infants in the treatment group showed a more rapid reduction in crying and slept more than control group infants.
Six online parent sessions focusing on sleep and behavioral interventions resulted in significantly improved scores on the Child Behavior Checklist items related to sleep, and sleep diary data showed reduced cosleeping and improved sleep onset with small effect sizes (Schlarb & Brandhorst, 2012, Level III). Mindell et al. (2011a, Level I) used the internet to deliver parent trainings related to infant sleep; statistically significant improvements were maintained at 1-yr follow-up (Mindell et al., 2011b), including improved sleep latency, reduced difficulty falling asleep, reduced number and duration of night wakings, and increased maternal confidence. Hall et al. (2015, Level I) used 2 hr of training by a registered nurse and biweekly phone calls over a 6-wk period to address behavioral sleep problems and found no significant differences in the number of nighttime waking episodes (determined through actigraphy and noninvasive monitoring of rest cycles); however, parents in the intervention group reported fewer wakings than did those in the control group. Providing parents with a booklet and companion DVD, a phone consultation at 6–8 wk, and a 1.5-hr parent group session at 12 wk of intervention resulted in no significant differences in infant sleep compared with the control group (Hiscock et al., 2014, Level I). In comparing two intervention groups using a coaching model targeting maternal reading of infant cues with different intensity levels, Kusanagi et al. (2011, Level II) found no change in infants’ sleeping or waking patterns. In a Level I study, nurses delivering a manualized sleep intervention at the 8-mo wellness visit found no significant difference between the intervention and control groups (Price et al., 2012).
Parent Training for Young Children
Moderate-strength evidence supports parent training as an intervention method to address sleep in children ages 2–5 yr. Three Level I studies and 2 Level III studies examined the impact of parent training on the sleep of children ages 2–5 yr; all studies had a moderate risk of bias and relied heavily on caregiver report. After a 15-wk program with 3 2-hr workshops and weekly phone calls, Austin et al. (2013, Level III) measured statistically significant decreases in sleep disturbance, total behavior problems, and nighttime waking at postprogram measurement. A single-group cohort study that provided 5 wk of behavioral intervention using graduated extinction found that typically developing toddlers showed statistically significant improvements on all measured sleep variables (i.e., total night sleep and sleep onset; Blunden, 2011, Level III).
An RCT that provided intervention focused on reducing the consumption of violent media and replacing it with short doses of prosocial and educational media found that the intervention group had a significantly lower likelihood of having any sleep problems (Garrison & Christakis, 2012, Level I). Compared with a non-sleep-related parent education group, an 8-wk parent-training program yielded a large effect size for improvements on the Composite Sleep Index at the 4- and 8-wk points for young children with ASD (Johnson et al., 2013, Level I). Delivery of two 2-hr parent training sessions with two follow-up phone calls yielded significant differences in sleep latency and efficiency (on the basis of actigraphy data) and total score on the Children’s Sleep Habits Questionnaire (Malow et al., 2014, Level I).
Touch-Based Interventions
Two Level I studies looked at the use of massage, and 1 Level I study examined the use of KC to improve infant sleep. All had moderate risk of bias. Touch-based interventions had moderate strength of evidence. A study comparing the effects of KC and being held while swaddled found that both groups increased their deep sleep, but the KC infants made significantly greater increases (Bastani et al., 2017). One week of mothers providing 15–20 min of massage twice daily with one session before sleeping resulted in statistically significant improvements in mean cry duration, duration of sleep, and colic severity compared with infants who were rocked by their mothers (Sheidaei et al., 2016). Massage provided 1 day in the NICU yielded significantly increased wakefulness, measured using actigraphy, during the day with massage versus the sequential day without massage (Yates et al., 2014).
Positioning Devices
Moderate-strength evidence supports the use of a positioning device. A Level I RCT (Lacina et al., 2015) looked at the use of a conformational positioner, which conforms around the infant in an individualized way, compared with standard positioning in the NICU and found that infants with the conformational positioner spent statistically significantly less time in awake alert, active awake, and crying states with improved sleep efficiency confirmed by electroencephalography data.
Moving Research Into Practice
The evidence in this section describes interventions supporting feeding and eating, toileting, and rest and sleep in early childhood. To support increased food intake, occupational therapy professionals have several options in early childhood, including mothers singing to their infants during nonnutritive suck, repeated exposure paired with behavioral reinforcement, and parent training in behavioral techniques. Use of a wetting alarm was effective in increasing toilet training in toddlers. Training parents to respond to their infant’s cries, use behavioral strategies, and use specific sleep interventions (i.e., KC, massage) resulted in a reduction in cosleeping and improved quality of sleep in early childhood. Occupational therapy professionals can recommend the use of touch-based interventions such as KC and massage to improve infant sleep. The evidence regarding effective interventions supporting toilet training is limited, and more research is needed. The research regarding occupational therapy–developed interventions for feeding and eating, sleep and rest, and toileting is also limited. It would be advantageous to increase the professional evidence supporting participation in ADLs for young children.
Case Vignette: Anthony
Anthony is a boy age 2.5 yr diagnosed with developmental delays. He was referred to occupational therapy because of difficulties participating in ADL routines. His parents report that they are most concerned about toilet training, behaviors during mealtimes, and his tendency to wake during the night. Anthony’s father stays home with him during the week, works on the weekends, and is eager to support Anthony’s growth in these areas. In completing the assessment process, the evaluating occupational therapist constructs an occupational profile for Anthony and uses multiple sources of information in formulating a treatment plan for him. She recommends intensive parent training to address Anthony’s mealtime and nighttime behaviors. She also provides ongoing supervision and collaboration with the occupational therapy assistant providing the intervention to update and monitor the treatment plan. Providing the parents with strategies to anticipate and better respond to Anthony’s needs using behavioral approaches has been successful in improving mealtime behavior (Johnson et al., 2015, Level I; Sobko et al., 2017, Level III) and reducing night waking (Austin et al., 2013, Level III). After interviewing the parents regarding previously implemented strategies to support toilet training, the occupational therapist recommends the use of a wetting alarm during the day (Vermandel et al., 2009, Level I).
Summary and Conclusion
Occupational therapy practitioners have many resources to support their clinical decisions. The body of literature and research examining interventions is continuously growing. It is imperative that clinicians stay abreast of the research and integrate it with their sources of practice-based evidence.
When addressing cognitive delays in children ages birth–5 yr, the research supports home-, community-, and preschool-based interventions. To address cognitive development in premature infants, occupational therapy professionals should recommend the use of NIDCAP, home-based EI, touch-based interventions, and reading aloud to the child and incorporating home programs when working in clinics. The REDI program, the Read It Again program, and teaching specific cognitive skills all improved cognitive outcomes for a range of preschool-age children who were at risk for or had a specific diagnosis associated with developmental delays. Occupational therapy practitioners should be aware of the programs informing local preschool programs and community services to assist families and teams in making the best choices for the child and caregivers. In addition, practitioners may want to pursue continuing education to strengthen their skills in addressing cognition in young children.
To address mental health outcomes, several interventions are moderately and strongly supported by the research. When targeting infant–maternal attachment, occupational therapy professionals should support skin-to-skin, KC, and parent training programs such as the MIT program. The Incredible Years, MIT, and teacher training in PBIS were all effective in improving child behavior. Occupational therapy practitioners may refer clients to local child care and preschool programs that use these approaches and should be versed in PBIS. To improve parenting behaviors, the research supports direct parent training, the Incredible Years, and PCIT for children ages birth–5 yr. Parent-delivered massage, attachment training, and the Play Project are all interventions that showed a significant impact on parental stress, anxiety, or depression. Therefore, when occupational therapy practitioners are aware of a parent’s risk factor or mental health diagnosis, it may be especially important to choose interventions addressing the child’s specific needs that also have an impact on caregiver mental health.
When addressing motor outcomes in children ages birth–5 yr, strong evidence supports the use of NIDCAP, CIMT, and BIT for children at risk for and diagnosed with CP, and it is important for clinicians to use, support, and refer these children to such interventions. Home-based interventions using parent coaching and clinic-based interventions that used home programs were also effective for short-term motor development, underscoring the value and benefit of well-written home programs and coaching parents to support their child’s development.
A variety of interventions with moderate and strong evidence are available to address ADLs. When addressing feeding and eating, repeated-exposure interventions, nonnutritive suck, and parent training to support the child’s feeding and eating are all effective options. The use of a wetting alarm is supported when toilet training toddlers. To address infant and child sleep, the use of parent training, positioning devices in the NICU, and touch-based interventions are all effective.
Occupational therapy practitioners can make comprehensive decisions across areas of need. For example, a child with cognitive and motor delays and sleep concerns may benefit greatly from parent-delivered massage. Practitioners can use this guideline to locate interventions that maximize the number of outcomes captured for each client. A case study is provided to illustrate the translation of the evidence into practice (Tables 9 and 10).
Case Example: Bhrodi’s EI Services
Note. CIMT = constraint-induced movement therapy; CP = cerebral palsy; DAYC–2 = Developmental Assessment of Young Children, Second Edition; DIR = Developmental, Individual differences, Relationship model; DMH = Department of Mental Health; EI = early intervention; IFSP = individualized family service plan; LBW = low birthweight; MD = physician; NG = nasogastric; NICU = neonatal intensive care unit; OT = occupational therapist; RN = registered nurse.
Case Example: Bhrodi’s Preschool Services
Note. ADLs = activities of daily living; CIMT = constraint-induced motor therapy; CP = cerebral palsy; ECSE = early childhood special education; EI = early intervention; GMFCS = Gross Motor Function Classification System; IEP = individualized education program; M-FUN = Miller Function and Participation Scales; NICU = neonatal intensive care unit; OT = occupational therapist; ROM = range of motion; STEM = science, technology, engineering, mathematics; VMI = Beery–Buktenica Developmental Test of Visual–Motor Integration.
Research regarding the use of specific occupational therapy interventions for children ages birth–5 yr has some gaps. Moving forward, it is important to address the quality of studies and control for bias to produce quality studies. Many studies included in this guideline relied on caregivers or teachers who were aware of the treatment condition, which had an impact on the strength of the evidence. In addition, many standardized measures may not be sensitive enough for test–retest after short doses (8–12 wk) of intervention. Occupational therapy researchers would benefit from measures sensitive enough to capture change over short courses of intervention.
Supplemental Materials
Supplementary material for Occupational Therapy Practice Guidelines for Early Childhood: Birth–5 Years
Supplementary material, sj-pdf-1-aot-10.5014_ajot.2020.743001.pdf for Occupational Therapy Practice Guidelines for Early Childhood: Birth–5 Years by Gloria Frolek Clark and Karrie L. Kingsley in The American Journal of Occupational Therapy
Supplementary material for Occupational Therapy Practice Guidelines for Early Childhood: Birth–5 Years
Supplementary material, sj-pdf-2-aot-10.5014_ajot.2020.743001.pdf for Occupational Therapy Practice Guidelines for Early Childhood: Birth–5 Years by Gloria Frolek Clark and Karrie L. Kingsley in The American Journal of Occupational Therapy
Footnotes
Acknowledgments
The authors acknowledge and thank the following individuals for their participation in the content review and development of this publication:
Deborah Lieberman, MHSA, OTR/L, FAOTA, Vice President, Practice Improvement, and Staff Liaison to the Commission on Practice, American Occupational Therapy Association, North Bethesda, MD
Elizabeth G. Hunter, PhD, OTR/L, Assistant Professor, Graduate Center for Gerontology, College of Public Health, University of Kentucky, Lexington
Sheena (Kramer) Bahls, RT (R)(MR)(CT), BS; Jayna Fischbach, PhD, OTD, OTR/L, BCP; Meredith Gronski, OTD, OTR/L, CLA; Hillary Richardson, MOT, OTR/L; Grace Sagester, OTD, OTR/L; Sandra Schefkind, OTD, OTR/L, FAOTA; Elizabeth K. Schmidt, MOT, OTR/L; Pam Stephenson, OTD, OTR/L; Kelly Tanner, PhD, OTR/L, BCP; Lindy L. Weaver, PhD, MOT, OTR/L; Chuck Willmarth, CAE.
The authors acknowledge the following individuals for their contributions to the evidence-based systematic review:
Margaret Bassi, OTD, OTR/L; Jayme Corry, OTD, OTR/L; Jayna Fischbach, PhD, OTD, OTR/L, BCP; Meredith Gronski, OTD, OTR/L, CLA; Kristen Martin, MOT, OTR/L; Emily Nadolny, OTD, OTR/L; Grace Sagester, OTD, OTR/L; Elizabeth K. Schmidt, MOT, OTR/L; Kelly Tanner, PhD, OTR/L, BCP; Taylor Vos, OTD, OTR/L; Lindy L. Weaver, PhD, MOT, OTR/L.
*
Indicates studies that were systematically reviewed for this practice guideline.
References
Supplementary Material
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