PT 215 - Movement Science 2 Professor O'Rourke Tuesday, July 19, 2011 All right. Thank you for your patience. Overall, how did that go? Male Student: Pretty well. Professor: Didn't the kids do great? All of them--all the way from 5 months to 2 or 3 [years]. I thought what we would do in the next half-hour is go through each child, and talk about what your experience was like, what were your observations. We'll look at your scoring and talk about how that relates to observations. Clearly today was not a typical environment for kids to display a full range of what they know, do, and are comfortable with. We'll do that for about half an hour, then we will talk a little about the assignment. (I want to reassure you that the model that is posted is the clinical one, not the expectations for the lab.) Then we'll go into the Peabody model--how to do it, looking at the measure--then run downstairs and set up the items and practice doing it. Let's talk about the little ones we saw today, starting with Eve. How did go? Your quick observations. Female Student: A little quiet. She was quiet at first and calling to her mother. It was hard to get her interested in what we were doing. After a while she started using the blocks and doing things. She didn't say much, and it sounded like she met a lot more of the criteria for her age group at home. She spoke, but we didn't get to see it today. Professor: This is a wonderful example of the difference between Group 1 and Group 2: coming in in the morning, strangers, anxiety about detaching. Though the length of time was about 20 minutes before she started engaging. What about the second group's experience? Female Student: She was social with us. She engaged with Ian, just wanted to play, and kept coming and sharing things with us. I think they had warmed her up for us. Professor: Exactly. Tomorrow you'll get to do the flip with some of the young toddlers. By the time she left, she really didn't want to leave the building, she was eager to hang out with Ian. It was a different experience, and a function of time. Marissa, can you or somebody else in your group talk about how she looked on the Ages & Stages? Female Student: I think she met most of the 22-month Ages & Stages: she could run and kick with both feet-- Female Student: She liked to jump a little. Female Student: She could hold herself up entirely in any position, she was talkative; she could match and label colors; she could pincher grip ... Professor: Personal/social: she was really active with Ian, mostly parallel play. Female Student: She was mostly parallel-playing with him. She was able to actually share, and she was engaging with us, able to bring us things. She did say some more words with us than with the first group, it sounds like. Professor: Before we leave her words and utterances, the rule of thumb is that a person of a year you expect to have a number of single words; by 2 they put words together. How was her language? Female Student: She would say more one word. Professor: Anything else? Female Student: One thing she didn't meet on the Ages & Stages was drawing: she couldn't draw a straight line. We talked to her mom about her speaking, and she said she's getting the two-syllabus words, and doing "My mama", really simple things like that. Professor: Any other observations you want to highlight? Female Student: A lot of it is the ease of movement between the positions, antigravity stuff. When she was on the floor she would sit up tall ... There is so much control and beauty in her movements. She would move her ankle around, wiggle her toes. The isolation of the single-joint movement is so great to see. Professor: The squatting, the up-and-down--all the transitions between positions. If you were to score her in the Ages & Stages, she would have typical development. Given what we've found in your readings and the milestones, does that match your observations? When you have a picture of someone at 21 months, under 2, does it look like she's doing what you would expect? Probably more. Standardized tests looked good, observations were good, and reports about what she is doing at home--this all fits together. Questions about Eve? Let's go to Ian, then, her little pal. Let's start with the first group. Male Student: When he first walked in, he stood at a distance and took us in. Nonna was fantastic getting him integrated. Comparing his observed behaviors--he came in walking on his own; he quickly exhibited a squatting behavior and movement. Professor: Other comments about Ian in the first group? Female Student: He wasn't really verbal, he was mumbling. He would say "Mama" and "Dada", but not more than that. He could identify an animal if you asked which one it was, but he wasn't interested in playing. He was impressive with his squatting, shifting to one way almost completely. Professor: The communication comment is really important, because perceptive language exceeds expressive language at this age. We're getting closer to understanding the range of language skills. Male Student: [His mother] felt like he was behind. Male Student: She made a comment that he was walking at an early age. This is her report. People who walk seem to have more advanced language skills. Professor: Often there's an asynchronous development. If you practice lots and lots of movement, it may be that your language and/or movement skills are moving along but not zooming. The second group will worked with Ian, he was engaged, comfortable. I thought the end part--would one of you like to describe him getting into and out of the little boxes? That was really interesting. Female Student: He was taking purple building for the steps. He would try to stack them on the floor, take them down, try to step into them, stack them onto each other, then step into that. We saw a lot of fine motor with the crayons, him taking them in and out of the box. He really likes to stack the boxes and take them off. It was really interesting to watch. Professor: The construction issue is really big for him right now. From a play perspective, that is a big area of interest. Any other observations about Ian? Female Student: He was incredibly persistent. There was a tub with a lid that snapped on into place. He kept tipping it upside-down ... He kept doing that over and over. Professor: That's a wonderful quality. Male Student: As I was going through the AIMS with him, it seems like it loses discrimination at around 18 months. He was 57 months. There's a big difference. Professor: Exactly. You hit a ceiling for that measure. I made that comment when we were talking with Will, who immediately looked up at the ceiling. [Class laughing.] It was really cool. All right, fantastic. Quinn. Two groups, eight students, had a chance to work with Quinn. He seemed relaxed right away. Any comments? You did do the AIMS. Female Student: He was very relaxed. He was just kind of sitting, taking everything in. He really likes taking things in and out of buckets, he was pretty thrilled with that. At first he wasn't moving around a lot, but after 15 minutes he was crawling and walking. In the end he was investigating with his big bald head. He was engaged in what was going on. He seemed to have a great time. It was nice to see him interacting with everybody, both his parents. When we were going through his AIMS he received a score a little lower than he got in class. We did the Ages & Stages and he was well above. Professor: Which is not surprising, given home versus a strange place. What was his Ages & Stages percentile at home? Female Student: 25. Professor: Which actually is pretty good. This is good for a raw score. Good. Other comments about Quinn? Again, this little guy is 13 months. Think about how confident he is. He looks just so comfortable, and he was able to do a lot. The second group for Quinn, any additional comments? Female Student: He colored for the first time today. He liked to eat [the crayons] too. Professor: Fairly easily for you to engage Quinn, and figure out what he was doing developmentally? Part of that is his development, and having Heather and Chris here. Heather: Comparing him to the other two kids, Quinn's motor movements were all over the map. He's a little wobbly when he's walking around, there was no controlled squatting down and coming back up ... Looking at his quality of movement, versus Eve's and Ian's, there was a big difference. But they'll all be at the same age in kindergarten. It's interesting to see them now, and know that in four years they'll be in the same playing field. Literally. [Class laughing.] Female Student: I was thinking about the variation in the different kids. Some of it is the age differences. Obviously, because their parents are bringing them here, they have involved parents. Where does parental skill play in, as far as these developments? Whether the parents know to give the children tummy time ... How soon does that present? Professor: We'll pick this up a lot next Spring--interaction between the child and their environment, as parents we are part of that. Going back to where we started: the key issue is the warm response of the loving relationship between the child and the parent, and having a safe environment, opportunities for feeding, etc. Certainly many children that we work with in early intervention are at-risk for a lot of reasons, like biological issues. With that set of circumstances, having a professional team, where we work together to figure out how to promote development, is important. Some children are at higher risk of developmental difficulties because their environment is fraught with many stresses. If you're living in a teeny little trailer in rural Vermont, and you don't have a car or access to one consistently, the opportunity to be in a big space, move around, and interact with other children-- that's going to be a very different kind of set of opportunities for the parents who came today, and for most kids. Thinking about all the influences is really important. In terms of the tummy time thing, little David hates being on his tummy. But he is so smart. He won't go there unless he absolutely has to. He's fine, he's figured out how to work around that with another strategy: "This is what I'm going to do, and you're not going to make me... even though I'm 9 months old." The rest of my colleagues, any comments? Peggy: There are extreme cases for kids in orphanages overseas that don't get as much interaction with adults that have delays. There are extreme situations where environmental deprivation does have lasting impact, but I think in this country we don't have that situation. Professor: Exposure to toxic stress in kids has a big impact on development. If anyone's interested in the Rumanian orphanage study--that is interesting--and foster care, I can give you a quick summary of that study. Let's talk about David, the guy who doesn't want to be on his tummy, 9 months old. The first group ... Female Student: One of the barriers was that his parents kept him up late. It was a balance of trying to see what he could do without getting him upset--part of this was not keeping him on his tummy. For the AIMS we couldn't score him for any prone activities. He definitely didn't want to be on his tummy, so we were able to get a lot of sitting postures. He could sit without support, rotate his trunk. We could see some of his postures in supine. They were saying that he primarily rolls from prone to supine ... It was a good lesson, in terms of being able to work with the child, and not push him past what he was comfortable with. Professor: It is important to pull together the interview, where you get your observations and the standardized measure, and the evaluation. This guy is just doing spectacularly, he just doesn't like to be on his tummy. He will probably sit on his bottom and pull himself along. The second group? He taught us a lot in the time we had with him. Female Student: We had to work quickly, because at that point he was pretty tired. It felt like this dance. His mom, maybe, was keeping him entertained, his dad was entertaining the older girls. He'd fuss and she had to settle him down. It was a dance, and we got to see that. It struck me that it was very different. We, at this point, can't play and take notes. We really depended on Mom to do the entertaining. We tried to shake a toy, get him to reach--"good, write that down." The one time he turned to prone, it was so fast that we missed it. You were there. You look at the rolling supine to prone, then score the lesser one. Professor: We didn't get to see whether he did it with or without rotation ... We did see him on his tummy for a few minutes. Your group may have gotten a score. Female Student: We scored him prone prop. We were debating whether we saw four-arm support, 1, as far as where elbows were. Male Student: We decided we wouldn't give it to him because we weren't sure. Female Student: So, we went down. Professor: If we add it all up, we could get an approximate. Needing to keep the whole family going, and delegating responsibility ... Female Student: If the kids are not used to me, they really cling to Mom. After a while, though, one guy really loved coming. He would bring in a big bag of toys. I would have a game plan, but it went out the door because he had all the toys. To him, the toys were definitely part of his family, and he wanted them involved. We never knew what would happen each time. Professor: The flexibility and creativity, and following along, are really important. Sometimes you have to abandon your plan, then come back to it. Any other comments about David? His big sisters were awesome. When they come on Thursday, it's all about the girls. They'll have their moment to shine. Female Student: David just lost his first tooth, so there were a lot of good stories to be told. Professor: Jane, 5 months old. Female Student: Her temperament was amazing, she was all smiles the whole time. You could put her in any position. She met all the 3-month and 7-month milestones. Professor: How did you find, for both groups, trying to score the AIMS with Jane? Was that a little easier, in terms of the pace of the movements? Female Student: We got through it pretty quickly because we were able to just put her in a position and watch. Female Student: We struggled a little. She was getting ready for her nap. She didn't like to be prone for very long. She was rolling well, she liked to be on her side. We didn't do standing or anything, she was just done. She was tired, a little fussy. Professor: Great. For the AIMS on a child that young, was it helpful to organize your observations? Male Student: Especially when she was getting tired. It required more prompting of the toys. Professor: So, it was helpful. Tamra: It was also clear why you wanted the book there with you. With the second group she wasn't doing much, and we had to go back to really look at the criteria. The same thing that Peggy said about the older group and looking at the variety of movement, you could say the same thing for her. Arms were going, legs were going, sometimes together; fingers, toes. That is such an exciting developmental thing to see in the little ones. When we get to abnormal, or atypical, development, it will be very striking how different that is. Keep that in mind the next time we meet. Somebody mentioned temperament, which can definitely play into gross motor development--which you'll see the rest of the week and in the Spring semester. I mean, she was so laid-back ... Professor: Most of us don't have children like that. She was incredibly calm. Great. Any last questions about Jane? Will, wasn't he adorable? Female Student: How old was Will? Professor: 17 months, not even a year and a half. Female Student: He was a little quiet when he first came in. "Who are these people staring at me?" The mom said he really likes balls. We started throwing the ball with him, and he got interested in that, kicking the ball. He initially started by holding onto something and kicking the ball, but we got him away from the chair he was holding on to, and he was running around and moving. He had quick, little fast steps, not like a run. Turning seemed to be an issue. Eventually we got him to play with some crayons, do some coloring, and do some stacking with blocks. Professor: And he is big. Percentage-wise, he's pretty much at the top of the chart, he's very tall; but he's very coordinated, excellent balance. Sign language--did any of you get to see him using his sign? Female Student: He signed for milk. He did know a bunch of other words, he said "Oh, no!" a lot. Professor: Pretty easy to work with Will? Male Student: His fine motor was good, too. He could open the bubbles, use two fingers ... Professor: All right, terrific. Thank you all. I think you all did just a spectacular job, and I thank you for your attention to the little ones and their parents. I want to clarify the components for the developmental assignment. It will be posted, but you'll have a hard copy as well. I will post examples of student work. The examples you'll see posted for each of the tools are from the realm of clinical practice, to give you a sense of how to use the information in interview and observation. We'll get to that next year. What you'll have posted are examples of student work--not that you need to emulate them, but they're there for you to look at. For each of the four developmental age groups--it will probably be a good idea to do it tonight while it's fresh--is create some kind of little developmental milestone, either a chart or diagram to hold it together. What are the children less than 2 doing? What are the differences in behavior? Pull together ways for you to easily recall things. Then, write up your observations for the child you worked with. What did you observe? What did you learn? Be specific across the behaviors. Then, write a brief summary of the developmental test and measure, as best you can with what you were able to complete. The reflection is really your own. What have you learned that's new, as a result of working with children in this particular age group? It may come from the infants, maybe it goes back to some of the videotapes. Just write down insights. This is a way to pull things together. It will be helpful for you to consolidate your knowledge, also it will be a document to take with you. Write 2-3 pages per age group. You can put it in your journal or give me hard copies. It can be whatever format. I think we are ready to learn about a new measure. Heather: I have a quick bit of feedback from last week, from my friends Mary and Jess. One of the things they were really impressed with about you guys was your level of professionalism. They were so surprised that so many of you introduced yourselves to them and asked them questions, and the interest you took with them. They were almost astonished! They didn't have any expectations coming here. They were really, really impressed with your level of professionalism, so I tip my hat to you. One the parents said, "Even though they know nothing about physical therapy, they really have that connection with people ..." [Class laughing.] Professor: Now we're going to learn about the Peabody. Female Student: For the assignment, can we do this in partners? Professor: No, this is one you need to do alone. Though you worked in a group, do this alone. It'll be really helpful for your own learning, because everybody had a different background experience. Female Student: For the developmental milestones part, do we just do it for the ages of the kids we worked with, or all the kids in that range? Professor: For the first one, birth through 21 months, do it for that range. Here's what I would recommend you think about: rather than get bogged down month by month, where you could forget the differences, think about clumping them. It may be the first 6 months, the second 6 months, for 7 and 12 months. Look at the milestones, and set it up in a way that will help you remember. Female Student: Mostly the motor milestones? Professor: No, all areas of development. Think about communication, social, fine motor for play ... Unless you really want to do it month-by-month, I suggest you don't do that. For your observations, it will just be for the child you saw. If you have other questions, we can talk about it. [On screen: Observe motor development] This might be helpful, as you're writing this up, to go back to when you're looking at categories. [On screen: Peabody Developmental Motor Scales-2] Peabody is the most commonly used motor school for preschool-aged children, and it was recommended for that big, national longitudinal child health survey. [On screen: PDMS-2] It is a tough one to administer, not always. Let's go through the characteristics: it is a standardized measure of gross and fine motor, it is not observation, but directed administration of specific test types, where we're looking for specific things based on a child's performance; it is normed for children 1 month to 6 years-11 months; it tests reflexes, stationary skills, locomotion skills (walking, jumping, kicking), etc. This is one of the tools that was re-normed recently. They did a really nice job re-norming. A large sample was represented, over 300 kids in each age range. One of the things about this measure is that it's not a parent report, you need to actually see the child perform the activities. Peggy: You get two you can take on parent report. Professor: It is both discriminative and evaluative. As a discriminative measure, we can compare the child's score to a normative sample. Children of the same age you can compare. It is also used as an evaluative measure for some children, to see how they change from one point in time to another. It's probably used more in a discriminative way, but it is used in both. Peggy and Tamra, jump in to expand. How do we go about administering this? We'll look at the score sheets. You determine the age of the child--and you will have birth dates--then start testing the items with what matches the child's age. If that is what looks like where they are, in terms of motor development, then we're able to start testing up, because we've found the base, or basal level. If we start at their age and we find they're not able to perform well at that level, we need to go backwards and find the level where they're having the most success. Peggy: For prematurity up to 2 years of age. If the child is premature, you subtract that. Professor: We'll show you how you get the age on the blackboard in a few minutes. Simplistically, start at the age; find the baseline where they're able to perform well; if it's at the age, you start going up; if not, keep going backwards in age until you've got the floor, or the basal level. Then you test upwards until the child is not able to perform: that becomes the ceiling. Peggy: To find the base, you have to have three scores in a row where the child has fully completely the task (baseline level); for the ceiling, you need three skills they perform at a zero level. Professor: We'll show you what this looks like on the sample in a few minutes. Items are scored on the three-point scale: 0 for can't do it; 1 for partial; and 2 for fully meeting the criteria. Once you have the raw score, you convert it, using the manual, to percentiles. (If a child is at the 43rd percentile, their score is better than 43 out of 100 children.) You can also get standard scores, which have a mean of 10 and a standard deviation of 3, so the scores are between 8 and 12 are within the average range. Age equivalence--I want to read you exactly what the manual says about those. Peggy, if you don't mind making a comment about age equivalence. Peggy: An age equivalent score is often misinterpreted by most people. It's a really bit of a dangerous score. If you have an age equivalence of 22 months and the child is 3 years old, parents will feel their child's skill is at a 22-month level. But that is not how you interpret the score. It's a dangerous score, and it can be very hurtful for families. Professor: Think of a situation in which a child has a condition where their movement is different--they could have cerebral palsy, Down's syndrome, or another condition. To say their movement is equivalent to a child much younger is not only incorrect, but very hurtful. Just to read what's in the manual--this was not true of the old manual--under age equivalence: "The use of age equivalence has come under close scrutiny ... [They] advocate discontinuation of these scores ..." For qualification purposes, sometimes parents are asked to provide this information. For us, as healthcare providers, we need to be fully aware of this. Female Student: Is there a better way? Professor: Yes. Percentiles actually work. Percentiles or standard scores are good to compare scores against a normative sample. The same is true when we look at growth. In comparison to the big sample, there is an indication that there's a delay or difference in development. Next Spring, you will learn about measures that were specifically developed for children with physical disabilities. Once we use this information to determine eligibility for services, because of a documented delay, we can move to another measure developed specifically for children with, say, cerebral palsy. These other measures more carefully evaluate change in development over time, not against a normative sample. Does that make sense? Female Student: It makes sense, but it wasn't quite my question. Though, it was helpful. Peggy said that it's incorrect to say to use a child's age equivalence as saying they move similar to a 4-year-old or a 4-month-old. How is the correct way to use that information? It's incorrect to say it "this" way ... Professor: The APA is saying not to use age equivalence, period. Instead, we use percentiles or standard scores. There's no good way to use age equivalence. Peggy: Some skills a child may be doing at a higher level, some skills a child may be doing at a lower level. It only means that their score has come down to that number, but it's not helpful for anyone to try to understand what that means. The one place I know that the age equivalent is used is in the schools, because you need to show the child has a 40% delay. The schools want to know the age equivalence, but it should never be reported out. You don't have to go down the path of saying what the numbers are, it's just harmful. Let's look at score sheets, and get into to talking in more depth how to report. Then we'll go downstairs and set up. [On board: 2008 7 19 2003 5 22] Think about your little ones for tomorrow. Peggy: Let's pretend this is today, because we have an example from 2008. The child was born in 2003, May 22nd. We need to figure out how old the child is in months. [Converting to months] One month and 5 years: this is a 61-month-old, almost a 62-month-old. Professor: That will be one of the early things we do tomorrow, making sure we get the date of birth converted. Male Student: What was the premature adjustment? Peggy: If it was a child under 2, and the child was 2 months premature, I would subtract 2 months from the overall months. Male Student: Is that how it's generally reported? Peggy: I usually report chronological and adjusted ages. Male Student: How does a parent say that? Professor: 38-42 weeks is term, at 31 weeks is almost 2 months premature. Depending on the parents' preference they might say the number of weeks, but they typically say months. One of the challenges, having done high-risk follow-up for infants born prematurely, is often times parents want to know both the score for that date plus the adjusted score. But it's really tough to look at providing information if the child is 2, 3, or 4 months premature, based on their chronological age; system-wise, they need to be adjusted, because biologically they're not that mature yet. After 2 it doesn't seem to make much of a difference. The reason to get to this level of the detail is that in the manuals we take the raw scores and look at the appendices, based on the months for the first year. Quickly let's look at this, then we'll go downstairs. Let's look at this example of a child at 57 months. [On screen: Child B 57 months] If you look to the start point in the far left column, start is 57-71 months, Item #24. Testing started at that level. We have had a 0, a 1, and a 1. Peggy: These are stationary skills. You start them stationary. You're on Page 5. Professor: We haven't found the basal, because the child wasn't able to do these. So, then we need to go backwards. The next level back: three 2's. You need three 2's in a row to set your basal, then you can continue forward. In this case, we kept moving forward until we got a 0-1-1-1 sequence. In this case-- Peggy: You keep going, you need three 0's in a row. You start with the first category for the child 51-57 months. You don't need to do all the items in the 57- to 71-month category. Depending on how they score, you move back to find the basal or forward to find the ceiling. Professor: A lot of items, but you don't do many, depending on the age. [On screen: Child B] Peggy, this is your writing, your example. I think this is an example-- Peggy: This is an example where you run out of things to test and you don't reach a ceiling (for stationary skills). You have 0, 1, 1, 1; then 2, 2, 0. The skills are really scattered. Professor: We'll talk about the scoring tomorrow. [On screen: Child B 57 months] This is an example of locomotion. He got three 0's in a row, so we keep testing. Keep going ... It's the test of threes. Three 0's in a row: that's your ceiling. Female Student: Is it at the 79 level or the 81 level? Peggy: It doesn't matter because you have three 0's for all three. You're just counting the points, not looking at the months. The three 0's won't modify the score at all. Male Student: It's a raw score, not a raw score out of items tested. Professor: Correct. Everything below the basal level gets a score of 2: the child has mastered those skills. That goes into your raw score, then you count up the points for where you start. With the raw scores, tally things up. [On screen: Peabody Developmental Motor Scales] [Reading chart] Age equivalent--go to the tables in the back of the manual, which allows you to convert the raw score to a percentile. This allows you to be able to compare that child's score to the normative sample. This is the real manual. We have borrowed manuals from Heather. I have photocopied some for teaching purposes, and they can't leave the lab. You have to buy the test scores, and you'll have to pay a little for that. Female Student: I'm confused with the terminology. Three 0's in a row is the ceiling; three 2's in a row-- Professor: That's the basal. The terminology is tricky. If you think about the AIMS, the basal is the least mature skill, it's the floor. The ceiling is when they can't do it anymore, the roof is the top. Between the basal and the ceiling is our window. Female Student: How does "Not tested" factor into the overall score, and how they compare to other kids? Professor: That's a great question, let's talk about that now. Peggy: Anytime I'm doing an evaluation like this, there's always something that comes up that I need to explain within my write-up. As I'm doing the scores, I say some items aren't tested, which drops the score. I may ask people and use it as a report if I really can't get it through testing. If I can't get it through report, I'll say, "This is the best that I could do at this time in this situation, and it may not be the most accurate measurement." Female Student: And it's not out of the amount of things tested. You're testing a lot of different things ... Peggy: The child spread-out over more pages loses points, because they're missing the 2's. Female Student: They get 2's for everything before that. Professor: Once you get your basal, everything is a 2 before that. It's a good question because it gets into interpretation issues. For measures that have been normalized over a large sample, a difference shouldn't matter when it gets converted. If the motor skills are within the normal range, it will reflect the normal range. We don't fudge it, we just write what we can do. We do the best we can do to get what we need. Are there any other comments about this, or should we jump down into lab? The way you're going to learn this best, and the most productive, is by thinking about the child you're administering this to tomorrow. We'll set up the lab for that testing situation, and we'll enter at the child's age. We'll prepare to go back and forward a few items, and you'll walk through how to do this with the manual and the score sheet. Eight o'clock will be early, and those little preschoolers will be raring to go. It'll be fun. [Lab] [End of class.]
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