Indian J Pediatr 1992; 59 : 681-685 i
Early Intervention Program (EIP) - The Indian Experiences
E.I.P.-SPASTN-Madras Experience Avanti Rao Spastics Socie~ o f Tamil Nadu, Taramani Road, Madras
Perceiving the lack of services for follow up and intervention therapy available to the survivors of neonatal intensive care units and their families, and to address it specifically, the Spastics Society of Tamil Nadu has begun a programme of hospital based services in the city of Madras, called Developmental Tracking Clinics for high risk neonates. These clinics have been operating from six Government hospitals and one private hospital for children, and are geographically located for optimal utilisation by a cross-section of urban and peri-urban dwellers. This programme was initiated in August 1990, and include detailed neuro-behavioural assessment and therapy apart from parent training. The popular term "infant stimulation" which describes general developmental stimulation, programmes for infants may be inappropriate in an approach based on pathokinesiology. Rather than needing more stimulation, many new borns, especially those with hypertonus or those with tremu-
Ious disorganised movements may have difficulty adapting to routine levels of noise, light, position changes and handling that are in operation in the NICU, in one-room tenements or in homes in the midst of busy thoroughfares. General stimulation can quickly magnify abnormal muscle tone and movement, increase behavioural state irritability and lability and stress fragile physiological mechanisms. Helpful assists such as cuddling, soothing touch, movement or positioning are often not available and the caretaker may not provide skillfully administered social stimulation when the infant is ready for it, or in an optimal state to receive and respond to it. With the above picture in mind the general goals of neonatal stimulation programmes would be: 1. To establish a fund of normal perceptual and motor experiences upon which later learning can be built. 2. To facilitate interactional skills such as visual and auditory orientation to the human face and voice. 3. To inhibit abnormal postural tone and movement patterns. 4. To support, counsel and train parents to be baby's first and best teachers. For intervention to be therapeutically relevant, the quality, quantity, frequency and duration should be individualised to specific
Many of us believe that Early Intervention Programs are not a regular feature in the Indian context, but going through some of the Indian experiences reveal another story. Articles included in this section may not satisfy all the journal criterias, but all the same they are experiences worth mentioning and could be a starting point for further studies-Guest Editor
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Vol. 59, No. 6
THE INDIAN JOURNAL OF PEDIATRICS
motor and interactive needs. The areas of developmental intervention are : 1. Positioning-programme should be diligently administered to promote movement and postural stability from positions of flexion. 2. Sensori motor intervention is the use of sensory modalities of tactile, vestibular, proprioceptive, visual and auditory stimuli to facilitate development. The primary orientation is eye contact with the mother and bonding. It is the eye which elicits maternal caregiving impulses and begins the process of interaction and communication between mother and child. Visual and auditory stimulation must be integrated into all parts of child-care or specifically reinforced as appropriate. Behavioural state and movement abnormalities can be influenced by swaddling and graded vestibular stimulation. 3. Feeding performance may be significantly improved by specific arousal or calming techniques before feeding. The neonate should be semiflexed with the chin tucked in and tactile stimulation of facial muscles, specific intra oral stimulation and/or manual stabilisation of the jaw may be utilised as necessary. 4. Parent training/counselling-strong continuous support is essential to help parents through, perhaps the most frightening crisis in their adult lives-the potential for death or disability of their baby. Actively listening to their feelings and concerns and explaining the situation is of paramount importance. Long range plans would include parent participation in all aspects of the developmental programme, but the timing and amount of initial teaching must be individualised to the levels of stress and acute grief present. The targets for parent teaching would include : 1. Reading cues from baby
2. 3. 4. 5. 6. 7.
Understanding sleep/awake states Calming techniques Levels of stimulation necessary Interaction and communication Eye hand co-ordination Independent handling and manipulation
Cues from the high risk baby may be harder for the parent to read than the lusty cries and ready smiles of the full term child. Stress or sensory overload could be recognised by the following signs-yawning, gaze aversion, blinking, tongue-thrnst, turning away, grimacing, sneezing and hiccuping, while interest is judged by an intent look or knitted brows. The high risk baby may have very little control over staying awake and may shift rapidly and unpredictably between being asleep, drowsy, calm or upset: Understanding this is essential for social interaction with the baby. Some infants may be lethargic and hard to rouse while others are irritable and slow to be soothed or calmed. Levels of stimulation should be gauged appropriately and previously mentioned signs of stress looked for. Interaction and communication depends upon noting the cues of the infant by the parents, and responding appropriately by adjusting or modifying their response; it takes extra sensitiveness and calmness to achieve this interpersonal synchronicity.
A 45 minute video film on "A Non-medical Assessment and Intervention of High Risk Neonates" is now available at the Spastics Society of Tamil Nadu, Opposite T.T.T.I., Taramani Road, Madras-600 113. Phone : 2350047
NAIRET AL : E.I.P-THEINDIAN EXPERIENCES
683
E.I.P-Bangalore Experience
ternal participation was the most important criteria for improvement.
Nandini Mundkur
Center for Early Intervention and Child Development, Malleswaram, Bangalore This programme is based on the assumption that the infant is not a passive recipient of information but actively participates in interactions, and is responsive to early stimulation. It is also assumed that development, particularly intellectual development, is subject to environmental influences also, The present study aims at laying down criteria for selection of cases and the factors which influences the outcome of E.I.P. Four hundred infants were screened at birth for developmental disabilities. Those infants classified in the established risk group were enrolled in the early intervention programme at birth, and those classified in the biological and environmental risk group were screened at 3'rd, 7'th, 10'th, and 12'th month of life by Bayley's mental scale. Any infant, found to have score below 70 were enrolled in Early Intervention Program. E.I.P. was structured programme with Vojta's method ~ for motor development and Upanayan programme for mental development. The thrust on the service was home based therapy with parental involvement to carry out the programme tailor made to each child. Reassessment at the end of 1 year of the ongoing program showed that all infants improved their DQ by 10-50 points. Maximum, improvement was seen in social skills followed by visuo-perceptual area. In motor development there was considerable improvement in reduction of spasticity, and no infant developed any contracture and daftdren moved towards uprighting ability. Ma-
REFERENCE 1. Vojta V. The basic elements of treatment according to vojta. In : David S. Manage-
ment of the Motor Disorders of Children with Cereberal Palsy. London : Spastic International Medical Publication, 1984.
E.I.P-Trivandrum Experience M.K.C. Nair, Suja Mathews, Babu George and Elsie Philip Child Development Center, Thiruvananthapuram The population for the present study consists Of those babies who are at increased risk for developmental delay and hence referred to the high-risk baby clinic; Child Development Center, S.A.T. Hospital, Thiruvananthapuram. After registering the case, details of the community risk factors, maternal risk factors and baby's risk factors are recorded as per the modified version of WHO questionnaire t in order to identify the possible additional risk factors contributing to the developmental delay in the child. Initially the child's medical status and the possible problems are discussed with the parents in order to create an awareness about the child's condition. Different handling and positioning techniques, and the home environmental stimulation are also advised to the parents. The babies are then followed up eve-ry four months interval at 4 months, 8 months and 12 months in order to detect any abnormalities if present, which could contribute to developmental delay or later
684
THE INDIANJOURNALOF PEDIATRICS
Vol. 59, No. 6
handicapping condition, and to intervene early so as to prevent and minimise the abnormalities as far as possible. At each visit the developmental status of the baby is assessed by the Denver Developmental Screening Test (DDST) 2 and the neurological status using Infant Motor Screen (IMS). 3 Then depending on the area of delay, the appropriate therapy is planned using mainly the neurodevelopmental treatment approach (NDT).4 The aim of this study was to gain experience with the follow up of babies at high risk for developmental delay, and to study the maternal, social and community factors contributing for optimal development of these babies. The following conclusions were made : 1. Although follow-up details of the cases are not a part of this presentation, our experience is that the concept of a high-risk baby clinic is well appreciated by the parents and actual participation enhance their child rearing capability. 2. Birth asphyxia is found to be the commonest risk factor. The next common risk factor was exaggerated neonatal jaundice followed by neonatal convulsions. The majority of cases had multiple risk factors. 3. It was also found that smoking is the major behavioural and environmental risk which can have negative effect on the developing foetus. 4. The maternal risk factor also has definite impact on the baby. The age of the mother, the history of previous sterility, the number of abortions, the type of labour, the number of deliveries, the spacing between two children, all can determine the mother's attitude towards the rearing of her child. 5. Mother's education, employment and health does have a direct effect on the
mother's action and reaction towards the factors interacting in her child's development and thus can determine the outcome of her child. 6. We also found that the type of family and the type of residence does influence the child. We conclude that community issues have got an important hand at every step of the child's development. Also, there is the need to emphasise to the parents, to regard the child as an individual and not just a miniature member of the family, and to provide appropriate opportunities which can enhance the child's hereditary potentials and better his performance in all areas of development. 7. We note that one or more perinatal, maternal and community risk factors Can coincide with each other, and inturn there can be an interaction of the sociological and biological factors which can make the child doubly vulnerable for normal development. Hence, early intervention and stimulation at the right time and in the right way using the services of the mother, father and grandparents is the positive answer to this problem. REFERENCES 1. Risk Approach for Maternal and Child health care.WHO offset Publication No. 39. WHO Geneva, 1978. 2. Frankenburg WK, Dodds JB. The denver developmental screening test. J Pediatr 1967; 71 : 181-84. 3. Robert EN, Catherine AR, J net SG. The infant motor screen. Dev Med Child Neurol 1989; 31 : 35-42. 4. Bobath K ed. A Neurophysiotogical Basis for the Treatment of Cerebral Palsy. Clinics in developmental medicine No. 75, Spastics International Medical Publications. Philadelphia : J.B. Lippincott Co, 1980 : 45-88.
Early Intervention Program (EIP) - The Indian Experiences
E.I.P.-SPASTN-Madras Experience Avanti Rao Spastics Socie~ o f Tamil Nadu, Taramani Road, Madras
Perceiving the lack of services for follow up and intervention therapy available to the survivors of neonatal intensive care units and their families, and to address it specifically, the Spastics Society of Tamil Nadu has begun a programme of hospital based services in the city of Madras, called Developmental Tracking Clinics for high risk neonates. These clinics have been operating from six Government hospitals and one private hospital for children, and are geographically located for optimal utilisation by a cross-section of urban and peri-urban dwellers. This programme was initiated in August 1990, and include detailed neuro-behavioural assessment and therapy apart from parent training. The popular term "infant stimulation" which describes general developmental stimulation, programmes for infants may be inappropriate in an approach based on pathokinesiology. Rather than needing more stimulation, many new borns, especially those with hypertonus or those with tremu-
Ious disorganised movements may have difficulty adapting to routine levels of noise, light, position changes and handling that are in operation in the NICU, in one-room tenements or in homes in the midst of busy thoroughfares. General stimulation can quickly magnify abnormal muscle tone and movement, increase behavioural state irritability and lability and stress fragile physiological mechanisms. Helpful assists such as cuddling, soothing touch, movement or positioning are often not available and the caretaker may not provide skillfully administered social stimulation when the infant is ready for it, or in an optimal state to receive and respond to it. With the above picture in mind the general goals of neonatal stimulation programmes would be: 1. To establish a fund of normal perceptual and motor experiences upon which later learning can be built. 2. To facilitate interactional skills such as visual and auditory orientation to the human face and voice. 3. To inhibit abnormal postural tone and movement patterns. 4. To support, counsel and train parents to be baby's first and best teachers. For intervention to be therapeutically relevant, the quality, quantity, frequency and duration should be individualised to specific
Many of us believe that Early Intervention Programs are not a regular feature in the Indian context, but going through some of the Indian experiences reveal another story. Articles included in this section may not satisfy all the journal criterias, but all the same they are experiences worth mentioning and could be a starting point for further studies-Guest Editor
682
Vol. 59, No. 6
THE INDIAN JOURNAL OF PEDIATRICS
motor and interactive needs. The areas of developmental intervention are : 1. Positioning-programme should be diligently administered to promote movement and postural stability from positions of flexion. 2. Sensori motor intervention is the use of sensory modalities of tactile, vestibular, proprioceptive, visual and auditory stimuli to facilitate development. The primary orientation is eye contact with the mother and bonding. It is the eye which elicits maternal caregiving impulses and begins the process of interaction and communication between mother and child. Visual and auditory stimulation must be integrated into all parts of child-care or specifically reinforced as appropriate. Behavioural state and movement abnormalities can be influenced by swaddling and graded vestibular stimulation. 3. Feeding performance may be significantly improved by specific arousal or calming techniques before feeding. The neonate should be semiflexed with the chin tucked in and tactile stimulation of facial muscles, specific intra oral stimulation and/or manual stabilisation of the jaw may be utilised as necessary. 4. Parent training/counselling-strong continuous support is essential to help parents through, perhaps the most frightening crisis in their adult lives-the potential for death or disability of their baby. Actively listening to their feelings and concerns and explaining the situation is of paramount importance. Long range plans would include parent participation in all aspects of the developmental programme, but the timing and amount of initial teaching must be individualised to the levels of stress and acute grief present. The targets for parent teaching would include : 1. Reading cues from baby
2. 3. 4. 5. 6. 7.
Understanding sleep/awake states Calming techniques Levels of stimulation necessary Interaction and communication Eye hand co-ordination Independent handling and manipulation
Cues from the high risk baby may be harder for the parent to read than the lusty cries and ready smiles of the full term child. Stress or sensory overload could be recognised by the following signs-yawning, gaze aversion, blinking, tongue-thrnst, turning away, grimacing, sneezing and hiccuping, while interest is judged by an intent look or knitted brows. The high risk baby may have very little control over staying awake and may shift rapidly and unpredictably between being asleep, drowsy, calm or upset: Understanding this is essential for social interaction with the baby. Some infants may be lethargic and hard to rouse while others are irritable and slow to be soothed or calmed. Levels of stimulation should be gauged appropriately and previously mentioned signs of stress looked for. Interaction and communication depends upon noting the cues of the infant by the parents, and responding appropriately by adjusting or modifying their response; it takes extra sensitiveness and calmness to achieve this interpersonal synchronicity.
A 45 minute video film on "A Non-medical Assessment and Intervention of High Risk Neonates" is now available at the Spastics Society of Tamil Nadu, Opposite T.T.T.I., Taramani Road, Madras-600 113. Phone : 2350047
NAIRET AL : E.I.P-THEINDIAN EXPERIENCES
683
E.I.P-Bangalore Experience
ternal participation was the most important criteria for improvement.
Nandini Mundkur
Center for Early Intervention and Child Development, Malleswaram, Bangalore This programme is based on the assumption that the infant is not a passive recipient of information but actively participates in interactions, and is responsive to early stimulation. It is also assumed that development, particularly intellectual development, is subject to environmental influences also, The present study aims at laying down criteria for selection of cases and the factors which influences the outcome of E.I.P. Four hundred infants were screened at birth for developmental disabilities. Those infants classified in the established risk group were enrolled in the early intervention programme at birth, and those classified in the biological and environmental risk group were screened at 3'rd, 7'th, 10'th, and 12'th month of life by Bayley's mental scale. Any infant, found to have score below 70 were enrolled in Early Intervention Program. E.I.P. was structured programme with Vojta's method ~ for motor development and Upanayan programme for mental development. The thrust on the service was home based therapy with parental involvement to carry out the programme tailor made to each child. Reassessment at the end of 1 year of the ongoing program showed that all infants improved their DQ by 10-50 points. Maximum, improvement was seen in social skills followed by visuo-perceptual area. In motor development there was considerable improvement in reduction of spasticity, and no infant developed any contracture and daftdren moved towards uprighting ability. Ma-
REFERENCE 1. Vojta V. The basic elements of treatment according to vojta. In : David S. Manage-
ment of the Motor Disorders of Children with Cereberal Palsy. London : Spastic International Medical Publication, 1984.
E.I.P-Trivandrum Experience M.K.C. Nair, Suja Mathews, Babu George and Elsie Philip Child Development Center, Thiruvananthapuram The population for the present study consists Of those babies who are at increased risk for developmental delay and hence referred to the high-risk baby clinic; Child Development Center, S.A.T. Hospital, Thiruvananthapuram. After registering the case, details of the community risk factors, maternal risk factors and baby's risk factors are recorded as per the modified version of WHO questionnaire t in order to identify the possible additional risk factors contributing to the developmental delay in the child. Initially the child's medical status and the possible problems are discussed with the parents in order to create an awareness about the child's condition. Different handling and positioning techniques, and the home environmental stimulation are also advised to the parents. The babies are then followed up eve-ry four months interval at 4 months, 8 months and 12 months in order to detect any abnormalities if present, which could contribute to developmental delay or later
684
THE INDIANJOURNALOF PEDIATRICS
Vol. 59, No. 6
handicapping condition, and to intervene early so as to prevent and minimise the abnormalities as far as possible. At each visit the developmental status of the baby is assessed by the Denver Developmental Screening Test (DDST) 2 and the neurological status using Infant Motor Screen (IMS). 3 Then depending on the area of delay, the appropriate therapy is planned using mainly the neurodevelopmental treatment approach (NDT).4 The aim of this study was to gain experience with the follow up of babies at high risk for developmental delay, and to study the maternal, social and community factors contributing for optimal development of these babies. The following conclusions were made : 1. Although follow-up details of the cases are not a part of this presentation, our experience is that the concept of a high-risk baby clinic is well appreciated by the parents and actual participation enhance their child rearing capability. 2. Birth asphyxia is found to be the commonest risk factor. The next common risk factor was exaggerated neonatal jaundice followed by neonatal convulsions. The majority of cases had multiple risk factors. 3. It was also found that smoking is the major behavioural and environmental risk which can have negative effect on the developing foetus. 4. The maternal risk factor also has definite impact on the baby. The age of the mother, the history of previous sterility, the number of abortions, the type of labour, the number of deliveries, the spacing between two children, all can determine the mother's attitude towards the rearing of her child. 5. Mother's education, employment and health does have a direct effect on the
mother's action and reaction towards the factors interacting in her child's development and thus can determine the outcome of her child. 6. We also found that the type of family and the type of residence does influence the child. We conclude that community issues have got an important hand at every step of the child's development. Also, there is the need to emphasise to the parents, to regard the child as an individual and not just a miniature member of the family, and to provide appropriate opportunities which can enhance the child's hereditary potentials and better his performance in all areas of development. 7. We note that one or more perinatal, maternal and community risk factors Can coincide with each other, and inturn there can be an interaction of the sociological and biological factors which can make the child doubly vulnerable for normal development. Hence, early intervention and stimulation at the right time and in the right way using the services of the mother, father and grandparents is the positive answer to this problem. REFERENCES 1. Risk Approach for Maternal and Child health care.WHO offset Publication No. 39. WHO Geneva, 1978. 2. Frankenburg WK, Dodds JB. The denver developmental screening test. J Pediatr 1967; 71 : 181-84. 3. Robert EN, Catherine AR, J net SG. The infant motor screen. Dev Med Child Neurol 1989; 31 : 35-42. 4. Bobath K ed. A Neurophysiotogical Basis for the Treatment of Cerebral Palsy. Clinics in developmental medicine No. 75, Spastics International Medical Publications. Philadelphia : J.B. Lippincott Co, 1980 : 45-88.
