Objective: Our objective was to evaluate the efficacy of the Sitting Together and Reaching to Play (START-Play) intervention in young infants with neuromotor disorders. Method: This randomized controlled trial compared usual care early intervention (UC-EI) with START-Play plus UC-EI. Analyses included 112 infants with motor delay (55 UC-EI, 57 START-Play) recruited at 7 to 16 months of age across 5 sites. START-Play included twice-weekly home visits with the infant and caregiver for 12 weeks provided by physical therapists trained in the START-Play intervention; UC-EI was not disrupted. Outcome measures were the Bayley Scales of Infant and Toddler Development, Third Edition (Bayley); the Gross Motor Function Measure; reaching frequency; and the Assessment of Problem Solving in Play (APSP). Comparisons for the full group as well as separate comparisons for infants with mild motor delay and infants with significant motor delay were conducted. Piecewise linear mixed modeling estimated short- and long-term effects. Results: For infants with significant motor delay, positive effects of START-Play were observed at 3 months for Bayley cognition, Bayley fine motor, and APSP and at 12 months for Bayley fine motor and reaching frequency outcomes. For infants with mild motor delay, positive effects of START-Play for the Bayley receptive communication outcome were found. For the UC-EI group, the only difference between groups was a positive effect for the APSP outcome, observed at 3 months. Conclusion: START-Play may advance reaching, problem solving, cognitive, and fine motor skills for young infants with significant motor delay over UC-EI in the short term. START-Play in addition to UC-EI may not improve motor/cognitive outcomes for infants with milder motor delays over and above usual care. Impact: Concepts of embodied cognition, applied to early intervention in the START-Play intervention, may serve to advance cognition and motor skills in young infants with significant motor delays over usual care early intervention. Lay Summary: If you have a young infant with significant delays in motor skills, your physical therapist can work with you to develop play opportunities to enhance your child’s problem solving, such as that used in the START-Play intervention, in addition to usual care to help your child advance cognitive and motor skills.

Play is an active process by which an individual is intrinsically motivated to explore the self, the environment, and/or interactions with another person. For infants and toddlers, engaging in play is essential to support development across multiple domains. Infants and toddlers with or at risk of motor delays may demonstrate differences in play or challenges with engaging in play activities compared to typically developing peers. Pediatric physical therapists often use play as a modality to engage children in therapeutic assessment and interventions. Careful consideration of the design and use of physical therapy that embeds play is needed. Following a 3-day consensus conference and review of the literature, we propose physical therapy that embeds play should consider three components; the child, the environment, and the family. First, engage the child by respecting the child’s behavioral state and following the child’s lead during play, respect the child’s autonomous play initiatives and engagements, use activities across developmental domains, and adapt to the individual child’s needs. Second, structure the environment including the toy selection to support using independent movements as a means to engage in play. Allow the child to initiate and sustain play activities. Third, engage families in play by respecting individual family cultures related to play, while also providing information on the value of play as a tool for learning. Partner with families to design an individualized physical therapy routine that scaffolds or advances play using newly emerging motor skills.

Although early intervention for infants at risk for cerebral palsy is routinely recommended, the content of intervention is poorly described, varies widely, and has mixed supporting evidence. The purpose of this study was to compare efficacy of 2 interventions grounded in differing domains of the International Classification of Functioning, Disability and Health on developmental outcomes of infants with or at high risk of cerebral palsy. Infants who meet inclusion criteria will be randomized into either Sitting Together and Reaching To Play or Movement, Orientation, Repetition, Exercise Physical Therapy groups. Both groups will receive intervention twice weekly for 3 months and follow-up at 3, 6, 9, and 12 months from baseline. The primary objectives compare changes over time and between groups in sitting, gross motor, and cognitive development. The setting is the infant’s home unless the caregiver requests otherwise. One hundred and fifty infants between 8 and 24 months of age will be enrolled in 3 geographically, racially, and ethnically diverse sites: Los Angeles, California; Omaha, Nebraska; and Seattle, Washington. Enrolled infants will demonstrate motor delays, emerging sitting skills, and signs of neurologic impairment. Sitting Together and Reaching To Play targets activities including sitting, reaching, and motor-based problem solving to improve global development. In contrast, Movement, Orientation, Repetition, Exercise Physical Therapy focuses on strengthening and musculoskeletal alignment while encouraging repeated movement practice. Outcome measures include the Gross Motor Function Measure, Bayley Scales of Infant Development-IV, Assessment of Problem Solving in Play, and a Parent Child Interaction assessment. Enrolled children will maintain usual intervention services due to ethical concerns with intervention withdrawal. This will be the first study, to our knowledge, comparing efficacy of early physical therapy with dose-matched interventions and well-defined key principles. The outcomes will inform selection of key principle of intervention in this population.

Purpose: Sitting delays in infants born preterm compound cognitive and language deficits. This retrospective study examines differences in prematurity-related risk and compares developmental outcomes between sitters and nonsitters at 6 months' adjusted age. Methods: A total of 105 graduates of the neonatal intensive care unit met inclusion criteria. Infant demographic and medical risk profiles and 6-month Bayley Scales of Infant Development-3rd edition (BSID-III) cognitive and language scores were retrieved. Infants who sat with hands free greater than 60 seconds were classified as “sitters.” Results: Sixty-nine percent of the sample were nonsitters and were born earlier, had lower birth weights, were chronologically older at follow-up, and spent more days with respiratory support. BSID-III scores were significantly higher in sitters but did not differ by gender, multiple birth, head ultrasound results, payment type, or race/ethnicity. Conclusion: Sitting abilities at 6 months' adjusted age are associated with prematurity risk factors. Cognitive and language scores differ significantly between sitters and nonsitters.

Purpose: This study examines object permanence development in infants with motor delays (MD) compared with infants with typical development (TD) and in relation to sitting skill. Methods: Fifty-six infants with MD (mean age = 10 months) and 36 with TD (mean age = 5.7 months) were assessed at baseline and then at 1.5, 3, and 6 months postbaseline. A scale was developed to measure object permanence (Object Permanence Scale [OPS]), and the Gross Motor Function Measure sitting subsection (GMFM-SS), and the Bayley Scales of Infant and Toddler Development, 3rd Edition (Bayley-III) were administered. Results: Interrater reliability of the OPS was excellent and correlation between the OPS and Bayley-III cognitive scores was moderately positive. Compared with TD, infants with MD were delayed in development of object permanence but demonstrated increased understanding over time and as sitting skills improved. Conclusion: In children with MD, object permanence, as quantified by the OPS, emerges in conjunction with sitting skill.

The development of independent sitting is associated with language development, but the learning experiences underlying this relationship are not well understood. Additionally, it is unknown how these processes play out in infants with motor impairments and delays in sitting development. We examined the real-time associations between sitting and caregiver speech input in 28 5–7-month-old infants with typical development and 22 7–16-month-old infants with cerebral palsy who were at a similar stage of early sitting development. We hypothesized that object labels would be more likely to co-occur with moments of optimal attention to the labeled object while sitting than while in other positions. Infants were video recorded in five minutes of free play with a caregiver. Coders transcribed caregivers’ speech, identified instances of object labeling, and coded infants’ and caregivers’ attentional states during object labeling episodes. We found that caregivers labeled more objects while infants were sitting than while they were in other positions. However, object labels were not more likely to co-occur with infant attention, infant multimodal attention, or coordinated visual attention to the labeled object during sitting. Infants with cerebral palsy were exposed to fewer labels and were less likely to be attending to objects as they were labeled than infants with typical development. Our findings shed light on a possible pathway connecting sitting and language in typical and atypical development.