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Infants and Young ChildrenVol. 17, No. 4, pp. 291300c 2004 Lippincott Williams & Wilkins, Inc.

Early Motor InterventionThe Need for New TreatmentParadigms

Gerald Mahoney, PhD; Cordelia Robinson, PhD, RN;Frida Perales, MEd

Results from a recent study indicated that neither of the 2 treatment models that are commonlyused with young children with motor impairment was effective in enhancing childrens rate ofmotor development or quality of movement, at least over a 1-year time period. These findings addto an increasing body of literature indicating that contemporary motor intervention proceduresare not adequately meeting the hopes and vision for motor intervention. These findings also serveas a call for the field to explore alternative treatment methods for providing services. In partic-ular, there is a need for greater involvement of parents in intervention. There is also a need fora renewed research agenda that explores issues related to the intensity of services and dynamicmotor theory. Funding models need to be modified to encourage recommended and innovativemotor intervention practices. Key words: cerebral palsy, Down syndrome, motor intervention,physical therapy

THE purpose of this article is to des-cribe and discuss the results of a re-cent study that examined the effectiveness of2 motor intervention approaches, Neurode-velopmental Treatment (NDT) and Develop-mental Skills (Dev Skills), with young chil-dren with Down syndrome and cerebral palsy(Mahoney, Robinson, & Fewell, 2001). Weconsider these findings in the context of cur-rent issues regarding the delivery of earlymotor intervention services. Specifically, wewill consider the following: (1) the degree towhich contemporary methods are achievingthe goals envisioned for early motor interven-tion; (2) efforts to involve parents in the inter-vention process; (3) the need to investigatethe effects of different degrees of interven-tion and focused practice on motor develop-ment outcomes; and (4) how funding poli-

From the Case Western Reserve University, Cleveland,Ohio (Dr Mahoney and Ms Perales); and theUniversity of Colorado Health Sciences Center,Denver, Colo (Dr Robinson).

Corresponding author: Gerald Mahoney, PhD, CaseWestern Reserve University, 10900 Euclid Ave, Cleve-land, OH 44106 (e-mail: [email protected]).

cies may work against mandates such as nat-ural environments, transdisciplinary models,instruction of parents, and use of assistivetechnology. Our discussion and recommenda-tions are informed not only by this study, butalso by our 25 years of experience in develop-ing, implementing, and evaluating early inter-vention programs for children with varied di-agnoses, including autism, Down syndrome,cerebral palsy, and developmental delays withunknown etiology.

INTERVENTION FOCUSEDON MOTOR SKILLS

The NDT and Dev Skills approaches are2 intervention models that are commonlyused in professional practice. NDT was de-veloped in England for treatment of chil-dren with cerebral palsy as well as adultswho experienced stroke (Bobath & Bobath,1964, 1984). NDT involves handling childrento inhibit abnormal tone and facilitate auto-matic reactions, such as righting and equi-librium, to promote normal movement pat-terns (Bly, 1983, 1991). It attempts to mitigatethe underlying impairments in the central

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292 INFANTS AND YOUNG CHILDREN/OCTOBERDECEMBER 2004

nervous system by guided practice of typicalmotor patterns (Butler & Darrah, 2001).

The Dev Skills interventions focus on learn-ing and mastering the normally sequencedmotor milestones, with intervention targetsidentified from skills at the next higher level(eg, Hanson & Harris, 1986). Instructionalstrategies tend to be behavioral in nature, thatis, children are encouraged to engage in ex-ercises or structured play activities that tar-get specific skills. The Dev Skills approach as-sumes that children will advance to higherlevels of motor development and indepen-dent functioning through guided practice andreinforcement. This approach is reflected inseveral commonly used early interventionscales and accompanying domain-specific cur-ricula. Examples include the Portage Guideto Early Education Program (Bluma, Shearer,Froman, & Hilliard, 1976); the Hawaii EarlyLearning Profile (Furuno et al., 1998); andthe Peabody Developmental Motor Scalesand Activity Cards (Folio & Fewell, 1983).

While our study was designed to comparethe relative merits of these 2 approaches, ourprimary purpose was to understand their im-pact as they were implemented in typicalpractice rather than controlled experimentalconditions. Thus, we followed a group of chil-dren who received services from community-based early intervention or therapy programsthat identified their treatment models as beingbased on either the NDT approach (n = 28)or the Dev Skills (n = 22) approach. We ex-pected that these 2 groups would use similarprocedures, but place greater emphasis on themethods and focus of the intervention modelwith which they identified.

To assess the merits of these 2 models, weexamined their impact in relationship to mo-tor impairments associated with different eti-ologies. For each treatment model our sam-ple included children with Down syndrome(n = 27) who tend to have delayed motor de-velopment associated with hypotonicity, andchildren with cerebral palsy (n = 23) whosemotor delays are associated with a range ofatypical motor patterns. We hypothesized thatthe Dev Skills approach would be more effec-

tive with children with Down syndrome be-cause motor impairments associated with thiscondition are not severely affected by atypicalmotor patterns, whereas NDT would be moreeffective with children with cerebral palsy be-cause of its focus on atypical motor patterns.

We also examined how several interventionand family factors mediate or contribute tothe effects of these 2 treatment models. Theeffects of any intervention are unlikely to besimply a function of the nature of the inter-vention, but rather are likely to be mediatedby a complex set of factors (Guralnick, 1997,2001). These factors include the following:the training of interventionists, frequency ofservices, comprehensiveness of the program,and the manner in which the parents are in-volved in services. Because parents play a ma-jor role in fostering their childrens develop-ment as well as implementing intervention ac-tivities at home, we examined how factorssuch as the level of support for parents andthe way that parents, primarily mothers, inter-act with their children contributed to motorintervention outcomes.

In summary, our study compared the ef-fects of NDT and Dev Skills motor inter-vention with a sample of 50 children whohad either Down syndrome or cerebral palsywho attended 9 community-based interven-tion programs located in different regions ofthe United States. We examined changes inthe rate of motor development and quality ofmovement from approximately 1 year of age(MCA = 14.2 months) over a 12-month period.We also examined how childrens etiology andfamily characteristics, including family func-tioning, social support, and parent-child in-teraction, contributed to motor interventionoutcomes.

WHAT WE FOUND

Diversity of motor interventiontreatment models

As anticipated, there was considerable over-lap between the treatments provided byNDT and Dev Skills interventionists. Both


Early Motor Intervention 293

groups focused on addressing specific mo-tor skills, tone/posture/alignment, quality ofmovement, and general motor activity or play.Although the predominant focus of both treat-ment models was on the development of spe-cific motor skills, 60% more NDT sessionsfocused on tone/posture/alignment, whereas70% fewer sessions focused on general mo-tor activity or play compared to the Dev Skillsgroup.

Both intervention models were con-ducted in a range of settings (home/clinic/classroom), with different types of providers,different durations of sessions, and withinearly intervention programs that variedsubstantially in the amount of services chil-dren and families received (eg, stand-alonetherapy, focusing on motor development vscomprehensive early intervention program).Dev Skills sessions were usually conductedby intervention specialists who were notphysical therapists, whereas NDT sessionswere delivered by physical therapists. DevSkills sessions tended to be longer than 45minutes (78% vs 23%), and occurred more inchildrens homes (38% vs 2%) and less in clin-ics (8% vs 24%) or center-based classrooms(54% vs 74%).

These 2 treatment models were associatedwith striking differences in parent involve-ment. There were differences in the numberof (a) sessions in which parents were present(73% for Dev Skills vs 41% for NDT); (b) ses-sions where recommendations were given toparents (80% Dev Skills vs 51% NDT); and(c) number of natural environment activitiesrecommended to parents (58% Dev Skills vs35% NDT). Mothers whose children receivedthe Dev Skills intervention received signifi-cantly more information about their children,more suggestions about activities to imple-ment at home, and more assistance obtainingother services.

Effects of intervention on rate ofdevelopment and quality of movement

To assess the impact of intervention onchildrens rate of motor development, we ad-ministered the Peabody Gross Motor Devel-

opment Scale (Folio & Fewell, 1983) at thebeginning and end of intervention. On aver-age, children had motor development quo-tients of 49 at the beginning of intervention(55 for children with Down syndrome; 42for children with cerebral palsy) and 48 after1 year of intervention (51 for children withDown syndrome; 44 for children with cere-bral palsy). There were no significant pre-postdifferences in motor development quotientsbetween children with Down syndrome ver-sus children with cerebral palsy, or betweenchildren who received NDT versus childrenwho received Dev Skills treatment.

We computed a Proportional Change In-dex (PCI, Wolery, 1983) to examine how chil-drens rate of motor development during in-tervention compared to their rate of develop-ment prior to receiving the intervention. Forthe entire sample the average PCI was 1.00.This finding indicated that the average motordevelopment rate children attained during in-tervention was equivalent to their rate of de-velopment prior to receiving the intervention.However, the distribution of PCI scores indi-cated considerable variability in developmen-tal rate changes. During intervention, 44% ofthe children decreased their rate of motor de-velopment by more than 10% (44.4% for chil-dren with Down syndrome; 43.5% for chil-dren with cerebral palsy), 32% maintainedtheir rate of development within a rangeof 10% (37% for children with Down syn-drome; 26% for children with cerebral palsy),and 24% increased their rate of developmentby more than 10% (18.5% for children withDown syndrome; 30% for children with cere-bral palsy). This pattern of developmentalchange did not vary significantly as a func-tion of the type of intervention model chil-dren received or childrens diagnosis (cerebralpalsy vs Down syndrome). While NDT pro-duced slightly better PCIs than did the DevSkills intervention (1.08 for NDT; 0.92 for DevSkills), these differences were not statisticallysignificant.

We assessed changes in the quality of chil-drens movement by using items from TheToddler Infant Motor Evaluation (TIME, Miller



& Roid, 1994) to rate several components ofmovement from videotaped observations ofchildren in multiple positions at the beginningand end of intervention. Because this use ofthe TIME was not a standardized procedure,we were unable to determine how observedchanges in quality of movement comparedto changes that might be expected becauseof maturation. However, the quality of move-ment findings were generally consistent withthe results for rate of development. During in-tervention, the group of children as a wholeimproved their quality of movement, but onaverage only at a level consistent with theirquality of movement at the beginning of inter-vention. In general, improvements appearedto be equivalent for children with Down syn-drome and children with cerebral palsy, re-gardless of whether they received the NDT orthe Dev Skills treatment models.

Do characteristics of intervention affectmotor intervention outcomes?

Several analyses were conducted to iden-tify characteristics of interventions that mightcontribute to motor intervention outcomes.Results suggested that factors such as the pro-fessional training of interventionists (eg, inter-vention specialist vs licensed physical thera-pist vs licensed physical therapist with NDTtraining), the degree to which program staffworked with parents, the location of services,and the comprehensiveness of services fami-lies received did not affect the childrens mo-tor intervention outcomes.

However, one finding was statistically sig-nificant. Although children had been sched-uled to receive at least 1 intervention sessioneach week, there was considerable variabilityin the number of sessions they actuallyattended. Number of sessions was the onlyvariable, other than childrens level of motorfunctioning at the beginning of intervention,which was a significant predictor of childrensmotor development improvement duringintervention. In a post hoc analysis of childrengrouped according to the number of sessionsattended, we found that high-attendancechildren (n = 23; Mean = 56.0; SD = 17.1)

attained a 14% increase in their motor devel-opment rate while low-attendance children(n = 22; Mean = 19.0; SD = 8.1) had a17% decrease in their motor developmentrate. High- and low-attendance groups werenot different with respect to diagnoses,type of treatment model, or level of motorfunctioning at the onset of intervention.

Do family characteristics affect motorintervention outcomes?

Measures of family functioning, social sup-port, and parent-child interaction were alsocollected at the beginning and end of inter-vention to determine how these factors con-tributed to intervention outcomes. Becauseof the lack of statistically significant relation-ships between these variables and childrensmotor development outcomes, none of thesefindings were included in the original report.Regression analyses indicated that neither thefamily environment or the social support mea-sures collected at preintervention and post-intervention nor mothers style of interactionat preintervention was significantly related tochildrens motor improvements. While ma-ternal directiveness at postintervention wasnegatively associated with childrens motorimprovement, it accounted for only 2% ofthe variance in their rate of development.We were unable to determine the relevanceof this finding to intervention, since nei-ther treatment model caused mothers tobecome more directive, and the effects ofmaternal directiveness on motor develop-ment did not differ between the 2 treatmentmodels.

DISCUSSION AND RECOMMENDATIONS

Contemporary treatment methods maynot be effective at achieving the goals en-visioned for early motor intervention? Con-sistent with findings from previous studies(Bower, Michel, Burnett, Campbell, & McLel-lan, 2001; Harris, 1997; Palmer, 1997; Palmeret al., 1991), results from this study present asobering picture of the benefits that children



with Down syndrome and cerebral palsyattained from participating in motor inter-vention. Whether children received servicesbased upon the NDT or Dev Skills treatmentmodels, on average their rates of motor devel-opment did not change during intervention.Our analyses of motor intervention outcomesin relationship to variables hypothesized tocontribute to the effectiveness of services re-vealed that only number of sessions con-tributed to childrens outcomes.

It is possible that the omission of a no-treatment control group in this study resultedin our underestimating the significance of ourfinding that nearly one third of our samplesustained, rather than decreased, their rate ofdevelopmental growth. Maintenance of thesame rate of growth as at baseline may bea legitimate outcome for some children withdisabilities. Yet, is the magnitude of this ef-fect sufficient in relation to the expense, timecosts, and disruptions to family routines ofindividual therapy appointments, whetherthey are in clinics or classrooms (Kaminer& Robinson, 1993; Snow, 2002)? We suspectthat few parents of children with disabilitiesor funders of service would be complacentwith such modest effects.

Our results add to the accumulating evi-dence that the treatment methods currentlyused in early motor intervention are weakat best, and fall far short of the hopesand vision upon which this endeavor wasoriginally based (Ketelaar, Vermeer, t Hartvan Petegem-van Beek, & Helders, 2001;Weindling et al., 1996). We do not serve thechildren and families we so passionately careabout by discounting disappointing researchfindings and sustaining the status quo. Asprofessionals we must acknowledge that al-though we need to continue serving childrenwith motor impairments and their families us-ing the best clinical methods available, at thesame time, we must become much more ag-gressive in our efforts to develop, evaluate,and integrate more effective treatments intopractice.

There is a critical need to take seriouslythe role of parent involvement in motor in-

tervention. Almost 25 years ago, Bronfenbren-ner (1979) concluded from a review of HeadStart Programs that early intervention effectswere associated with the degree to which pro-grams worked directly with parents. Bronfen-brenner observed that young childrens learn-ing is not restricted to instructional activitiesthat take place in clinics or classrooms, butrather occurs throughout their daily environ-ments. Parents have more opportunities topromote childrens development and partic-ipation in these environments than do pro-fessionals. Although Bronfenbrenners conclu-sions were based upon evaluations of childrenwho were at risk for developmental delays,there is no reason to believe that his conclu-sions do not apply to infants and toddlers withdisabilities as well.

A few years ago, we published an analysis ofthe developmental outcomes that 635 infantsand toddlers with, or at risk for, disabilitiesattained in 4 intervention research projectsthat provided compelling support for Bron-fenbrenners thesis (Mahoney, Boyce, Fewell,Spiker, & Wheeden, 1998). Results indicatedthat when early intervention not only workedwith parents but also helped them learnmore effective ways of interacting with theirchildren, it successfully promoted childrensgeneral development. However, when inter-vention did not help parents interact moreeffectively with their children, it had little im-pact on childrens developmental growth, re-gardless of the intensity of services childrenand families received.

During the last 5 years, a number of ar-ticles related to parent involvement in mo-tor intervention have been published. Thesearticles have argued for parents playing amore central role in motor intervention(Darrah, Law, & Pollack, 2001); provided dataindicating that parents are comfortable withthis role (Sayers, Cowden, & Sherrill, 2002);and demonstrated that parent involvementcan have a positive impact on motor inter-vention effectiveness (Hamilton, Goodway,& Haubenstricker, 1999; Ketelaar, Vermeer,Helders, & Hart, 1998; Torres & Buceta,1998).



While the interventionists in our study re-ported working with parents, there was con-siderable variability in what they did and howmuch they worked with them. Furthermore,these interventionists were not successful athelping parents acquire patterns of interac-tion that might be more effective at promotingchildrens motor growth. In spite of their ef-forts to work with parents, their interventionstended to be more professionally driven thanparent mediated. Parents were not present foralmost 50% of all sessions, and only 18% of thesessions took place in childrens homes or nat-ural environments.

Certainly one plausible explanation forthe disappointing outcomes observed in ourstudy was the fact that interventionists car-ried out their role more by working directlywith children as opposed to working collabo-ratively with parents. Very likely, this situationdid not occur by design, but resulted froma variety of factors that are known to limitparent, involvement. Perhaps many parentswere unable to participate because of job orother family responsibilities; some may haveresisted becoming involved; while for others,interventionists may have refrained from at-tempting to involve parents fearing that thiswould unduly stress or overwhelm them.

Particularly in light of the Individuals withDisabilities Education Act (IDEA) Part C man-date for early intervention to enhance the ca-pacity of families to meet the special needs oftheir infants and toddlers, the time has cometo stop talking about parent involvement andto commit to learning how such involvementcan be accomplished across a range of fam-ily constellations, circumstance, and values.This is not a simple shift. It will require usto conduct research to help us better un-derstand how parents actually influence chil-drens motor development. It will also requireus to develop service delivery options and in-tervention procedures that are less stressfuland more accommodating to parents. Serviceand funding agencies must stop conceptual-izing motor intervention as the activities pro-fessionals do to children, and begin to takeseriously the idea that intervention fundamen-

tally entails empowering parents and othersto support childrens motor development intheir daily routines (Kaminer and Robinson,1993; Mahoney et al., 1999).

We need to become more active in pur-suing a national/international motor inter-vention research agenda. Although we main-tain that parent involvement is essential foreffective motor intervention, parent involve-ment will be beneficial only if they are pro-vided recommendations and motor interven-tion strategies that are truly effective.

In reviewing the results from our own studyas well as results from other recently pub-lished motor intervention studies, we can-not help but wonder whether there might befundamental flaws with the treatment meth-ods and strategies used in contemporary prac-tice. If the procedures examined in our studywere valid, one or the other treatment mod-els should have worked under one or a com-bination of the conditions we examined (eg,diagnosis, service setting, comprehensivenessof services, professional training of interven-tionists), but they did not. For too long re-searchers have been apologetic about report-ing negative intervention results, cautioningthat their failure to find treatment effectscould be attributed to flaws in the analy-ses, such as inadequate assessment measures,nonexperimental research designs, and smallsample sizes (Harris, 1997; Palmer, 1997).However, a recent review by Seibes, Wijnroks,and Vermeer (2002) reported that the qual-ity of motor intervention research reported inthe 1990s improved dramatically from the re-search reported in the 1980s, but still therewas little, if any, improvement in motor inter-vention outcomes.

Aside from a few recent promising pro-grams of research, the most notable feature ofcontemporary motor intervention research isthe lack of it. Harriss review of motor inter-vention for young children with cerebral palsyprovides a startling illustration of this obser-vation (Harris, 1997). Over a 10-year time pe-riod (19871997), she identified fewer than10 published studies investigating these is-sues. This would not be so alarming if clinical



procedures yielded consistent, positive treat-ment effects, but such results are not the case.

However, there are at least 2 areas of re-search that hold promise for enhancing the ef-fectiveness of motor intervention procedures.The first is related to the issue of intensityofservices. Similar to findings reported by Mayo(1991), results from our study yielded onlyone significant intervention effect, and thiswas related to the intensity of services chil-dren received. Regardless of childrens diag-nosis or the type of treatment they received,children who were high attenders made sig-nificantly greater increases in their rate of mo-tor development than did children who werelow attenders. The question of how much ser-vice children must receive to attain an inter-vention effect is an issue that, if not addressedby research, will continue to be dictated by ar-bitrary decisions made by administrators andfunders of services.

While our findings related to intensity wereprovocative, they were also perplexing. Ourhigh attenders who averaged slightly morethan 1 session per week made modest mo-tor improvements, while our low attenderswho averaged approximately 1 session every3 weeks showed no intervention effect at all.If, as these data imply, there is truly a dosageeffect to motor intervention, than perhaps ourfailure to find meaningful intervention effectsis the result of children not receiving suffi-ciently intensive services.

On the other hand, since the frequency ofservices received by the high attender groupcan hardly be characterized as Intensive,particularly compared to the 15 to 40 hours ofweekly intervention services recommendedfor children with autism (Dawson & Osterling,1997), it may be that the effect we observedhad little to do with the intensity of serviceschildren received. Rather, this effort may havebeen related to children having different num-bers of opportunities for motor learning, notonly in intervention but in their natural envi-ronments as well. Consistent with the notionof parent involvement discussed above, it ispossible that the different attendance rates ofthe high and low attenders may have been a

reflection of the different levels of personal in-vestment these 2 groups of parents had in en-suring their childrens general opportunitiesfor motor learning. In either case, intensity ofservice is an intervention factor that is oneof the most critical issues facing parents andadministrators. It is absolutely essential thatresearch be conducted to guide decisions re-lated to this factor.

A second promising line of research is re-lated to the use of Dynamic Motor Theory(Thelen & Ulrich, 1991) as a foundation forthe development of intervention procedures.This theory views motor development as aprocess by which children construct solu-tions to motor problems. New motor behav-iors evolve from children using their uniquecharacteristics and capacities to explore situ-ations through which they discover new andmore adaptive forms of gross motor behavior.To accomplish such tasks, infants must attendto the information generated by their ownbodies as well as the information available inthe context. This theory of motor learningnot only highlights the importance of child-initiated motor activity but also emphasizesthat childrens intrinsic dynamics (eg, activelearning) play a major role in the acquisitionof more adaptive motor behaviors.

The implications of this theory for prac-tice have yet to be fully delineated (CaseSmith, 1996). Nonetheless, this theory chal-lenges the value of clinical motor interventionprocedures that emphasize passive movementexercises and didactic instruction of motorskills. One promising line of research toevolve from this tradition is the work of Ul-rich and his colleagues investigating the ef-fects of spontaneous stepping practice onthe rate that children with Down syndromelearn to walk (Ulrich, Ulrich, Angulo-Kintzler,& Yun, 2001). In addition to receiving tra-ditional physical therapy, parents providedtheir children with practice stepping 5 daysa week for 8 minutes each day by supportingthem on specially engineered miniature tread-mills. The intervention began when childrenwere approximately 10 months old and con-tinued until they were independent walkers.



A Treatment versus No Treatment research de-sign indicated that this type of spontaneousstepping practice helped children with Downsyndrome walk independently approximately100 days sooner than did the children who didnot receive the treatment.

Consistent with the principles of DynamicMotor Theory, the Ulrich study demonstratesthe potential influence that spontaneousmovement can have on childrens motorlearning. If such robust effects can occurwhen children receive only modest (8 min-utes per day) amounts of arranged practice,might not more dramatic effects occur ifwe enhance childrens spontaneous activitythroughout their daily routines? Research re-ported by Hanzlik and Stevenson (1986) mayprovide an important clue as to how this re-sult could occur. These investigators reportedthat young children with cerebral palsy en-gaged in greater amounts of spontaneous mo-tor activity when their mothers interactedresponsively rather than directively withthem. Perhaps Functional Physical Therapy(Ketelaar et al., 2001) can become a morepotent intervention if we conceptualize func-tionality in terms of adults interacting respon-sively to support and encourage children toengage in the motor activities that interestthem throughout the day (Okimoto, Bundy, &Hanzlik, 2000).

Policy and funding barriers torecommended practice

While we did not gather data regardingfunding of services in our study, we do havea great deal of anecdotal data as to how fund-ing sources and policies impact service mod-els. For example, in Colorado, during the timeof this study, funding from Medicaid paid amore favorable rate to hospital-based outpa-tient therapy departments then to individualproviders. To be reimbursed at the more fa-vorable rate, the service had to occur on sitein the clinic, an approach that contravenedthe mandate to provide intervention in thehome or in places where one would expectto find children without disabilities, ie, natu-

ral environments.Home-based services couldonly be funded by Medicaid if the child wastoo fragile to transport. In addition, the ratepaid to a Home Health Agency was basedupon a fixed charge for a procedure ratherthan billing for time, which was the case forclinic-based services. The Home Healthpro-cedure rates were typically developed basedupon adult models where a visit might be forproviding 20 minutes of range of motion exer-cise. These rates did not adequately compen-sate recommended activities such as instruc-tion of the parent in problem solving arounddaily care routines or visiting the neighbor-hood park to see what adaptations might beprovided to enable a child to play with otherchildren.

Use of a transdisciplinary model that is rec-ommended for its presumed efficiencies inresource allocation and potential for provid-ing a better coordinated intervention is oftencontravened in policy and funding, becauseit is not possible to recover costs of the leadinterventionist receiving consultation fromcolleagues in other disciplines. Providing in-struction to parents and other caregivers isconstrained by policies that are perceived asstipulating that only services that involve di-rect hands on activities with the child arebillable time. Undoubtedly, perceived andreal barriers such as these contributed to thelimited instruction of parents that we ob-served in our study. Reimbursement policiesfavoring direct hands-on intervention morethan consultation have been a driving forcefor a professionally driven, pull out modelof therapy.

CONCLUSION

The purpose for reviewing the results fromour study was not to dwell on the negative,but to emphasize the critical need for researchand development related to early motor in-tervention. Recommendations from the Na-tional Research Council Committee on Educa-tional Interventions for Children with Autism(Lord & National Research Council Commit-tee on Educational Interventions for Children



with Autism, 2001) offers an excellent tem-plate for the issues to be addressed to en-hance the effectiveness of motor interventionservices. Specifically, this committee articu-lated the need for (1) detailed description ofcharacteristics of both children and familieswith whom interventions are implemented;(2) manualization of treatments; (3) assess-ments of the fidelity of treatment implementa-tions; and (4) documentation of child progressin both acquisition and generalization of skills.

In addition we recommend that this work beguided by the ICF framework (WHO, 2001)to gain clarity regarding the purpose and out-comes of specific interventions. Funding poli-cies are needed to support the expectationfor intervention services to include collab-oration with parents, as well as to providethe adaptive equipment and assistive tech-nologies needed to ensure that children withmotor impairments can participate in typicalroutines.

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