Down Syndrome: Sensory Integration, Vestibular Stimulation and Neurodevelopmental Therapy Approaches for Children Mine Uyanik, Ph.D.

Hacettepe University Faculty of Health Sciences, Physiotherapy and Rehabilitation Department, Ergotherapy Unit Ankara, Turkey muyanik@hacettepe.edu.tr Hulya Kayihan hkayihan@hacettepe.edu.tr Hacettepe University Faculty of Health Sciencies Department of Physical Therapy and Rehabilitation Occupational Therapy Unit 06100 Samanpazari Ankara-TURKEY Table of Contents Article top Abstract Definition of Child with an intellectual disability Normal Motor Development Sensory Integration Theory Assessment Interventions in Sensory Integration Dysfunctions The Role of the Vestibular System in Motor Development Neurodevelopmental Therapy Approach Combined Interventions Family Education References Further reading Read this article in other formats and languages Cite this article Copyright Search Read a shorter, less technical version of this article Abstract Down Syndrome is a disability characterized by significant limitations both in intellectual functioning and in adaptive behavior as expressed in conceptual, social, and practical adaptive skills. There are various degrees of sensory integration dysfunctions in children with an intellectual disability. Sensory integration is the organization of sensory input for use. Function of learning depends on the child's ability to make use of sensory information in order to perceive sensory information from his environment, integrate this information and plan and form purposeful behavior. Sensory integrative intervention, vestibular stimulation, neurodevelopmental therapy approaches are effective methods used as occupational therapy/ physiotherapy interventions in separate or combined programs with educational, behavioral and pharmacological interventions in children with an intellectual disability. Definition of Child with an intellectual disability The Diagnostic and Statistical Manual (DSM-IV) (American Psychiatric Association 1994) and ICD10 Classification of Mental and Behavioral Disorders (World Health Organization 2008) classify individuals with child with an intellectual disability according to the severity (mild, moderate, severe, profound, other and unspecified) of the impairment in intellectual functioning. The American Association on Intellectual and Developmental Disabilities (AAIDD) has defined an intellectual

the primitive reflexes decrease as the postural or automatic reactions appear. the life functioning of the person with child with an intellectual disability generally will improve. Aubert 2008). The development of postural control in children occurs in stages to their ability to integrate sensory information. standing and walking. As the infant develops and gains greater control of movement against gravity. dealing with social needs is very important for children with an intellectual disability. The child first learns a skill and generalizes it to other circumstances. In adaptive behavior impairments. community use. Characteristic of the muscles in the musculoskeletal system. Primitive reflexes are spontaneous. and behavioral factors. base of support and centre of gravity affect the development of movement.disability in a child as a disability characterized by significant limitations both in intellectual functioning and in adaptive behavior as expressed in conceptual. An important purpose of describing limitations is to develop a profile of needed supports. Classification and System of Support for the importance of adaptive behavior with relation to children with an intellectual disability. home living. coming to a sitting position. if the individual has limitations in two or more adaptive areas and an intelligence quotient (IQ) of 70-75 or below and the age of onset is 18 or below. also called automatic reactions. Between the ages of 7 and 10 responses similar to those of adults are observed. General movements and reflexes enable voluntary and adaptive motor control. functional academics. Within an individual. social. With appropriate personalized supports over a sustained period. 1993). AAIDD has suggested a 3-step process of Diagnosis. self-care. The fundamental source of postural stability in children and adults is somatosensorial. leisure and work. At these ages the proprioceptive system generates simple and incomplete information. and practical adaptive skills. In defining children with an intellectual disability. variable responses to stimuli. Postural reflexes are seen throughout life. social skills. Neuromotor factors There are two kinds of reflexes: primitive and postural reflexes. Movement and posture are learned in a sensory state or environment. and coordinated movement takes place (Woollacott and Shumway. postural control develops first and provides the basis for movement. sensory. In this system. Normal Motor Development Normal development of movement and function is essential to the child's motor control achievement and learning. Achievement of postural control is significant for endurance against gravity and muscle strength (Martin 1989). movement of joints. limitations often coexist with strengths. Factors affecting the ability of movement Factors of the musculoskeletal system Mechanic factors such as gravity. Between the ages of 1 and 3 the sense of sight is dominant. gravity line. Valid assessment considers cultural and linguistic diversity as well as differences in communication. health and safety. Motor learning develops in stages. Adaptive behavior is the sum of many abilities in order to achieve community integration. crawling. self-direction. AAIDD (2008) has specified five assumptions essential to the application of the definition: Limitations in present functioning must be considered within the context of community environments typical of the individual's age. Between the ages of 4 and 6 somatosensorial and vestibular input is greatly used. peers and culture. motor. Martin 1989.Cook 1986. The infant should move actively to gain basic motor skills such as rolling. Practice is needed for the somatosensorial system to utilize proprioceptive information effectively. which originates before the age of 18 (AAIDD 2008). Postural reactions appear in the . there are ten adaptive areas considered critical to a diagnosis of a child with an intellectual disability: communication. joint range. Adaptive behavior signifies the quality of daily performance in dealing with environmental needs. ligament range. and it is a powerful sense for achieving and maintaining the orientation of the upright position. and tension of muscles are important factors for the development of maximum performance. the individual can be diagnosed as a child with an intellectual disability (Lambert et al. and aim at keeping the head and body in an upright position. stereotypical responses to a specific stimulus. Physical activity is necessary for motor development.

These dysfunctions observed in children with Down syndrome may also continue after preschool and adolescence periods. radial digital prehension. protective. the infant gains control of the head. joint hypermobility. Uyanik et al. The aim of the righting reaction is to maintain the correct orientation of the head and body. This process enables the spatial-temporal usage of the sensory information the individual gets from his body and . Haley 1987. Protective reactions are extremity reactions to rapid displacements of the body by horizontal or diagonal forces. the infant is able to rolling supine to prone segmentally. 1990. Moni and Jobling 2000). For the maintenance of stability. twelve months. Due to the develop child with an intellectual disability of the cerebellum and the brainstem. 2001. Sensory Integration Theory Sensory integration is "the organization of sensory input for use" (Ayres 1979). and equilibrium. the infant can come to a sitting position without help. Stratford and Ching 1989. Kerr and Blais 1985. opportunity etc. the infant starts pulling to stand. Jobling and VirjiBabul 2004. Various studies have shown that children with Down syndrome generally have deficits in eyehand coordination. At eight months. equilibrium and visual motor control (Henderson et al. Specifically. Fine motor development is characterized by the following milestones: The child gains the ability of raking. Therefore. six months. palmar grasp. the speed in gaining these abilities may also change (Martin 1989. Aubert 2008). Equilibrium reactions occur during the changing of the centre of gravity by the movement of the body or support surface (Martin 1989. Between 12 and 18 months. cultural differences and the child's previous experiences may change this order. it is essential that therapeutic programs which increase the stimulation of postural reactions are utilized in the intervention program. At nine months. The formation of postural synergies and sensory inputs through integration is important in the therapeutic approach (Haley 1986). five months. 1981. rapid-automatic postural responses should occur. Shumway-Cook and Woollacott 1985. Around three months. Down syndrome and neuromotor control In children with Down syndrome. Woollacott and Shumway-Cook 1986. the infant begins to display a decrease in physiologic flexion along with an increase in active extension against gravity while in a prone position. Around the fourth month. Connoly and Michael 1986. The term sensory integration which signifies a neurological process was first developed by Ayres. and plays a role in the voluntary control of muscles. maintenance of primitive reflexes. dysfunction of stereognosis and decrease in motor skills are also related to hypotonia. Between six and eight months. The occurrence of balance and coordination problems in these children supports the view that individual therapy may be useful not only during preschool period but also during all adolescent life (Connoly and Michael 1986. 2006). Aubert 2008). delays in postural reactions take place with the delays in motor development. N. Creeping has become the main means of mobility for the 910-month-old child. In children with Down syndrome. reaction timing. some children with Down syndrome need to develop strategies in order to eradicate useless sensory inputs. At four months. Milestones of gross and fine motor development From one to two months. the infant can walk independently (Aubert 2008). Due to other individual differences for example motivation. laterality. nine months.following order as reactions of righting. the baby has good control of the head and displays strong control against gravity. eleven months and neat pincer prehension. and as a result body posture and the quality of movement are affected (Woollacott and Shumway-Cook 1986). decrease in deep tendon reflexes. Dyer et al. there have been a number of observed and measured motor characteristics such as hypotonicity. At six months. the infant shows more symmetry in alignment and movement of the body. In children with Down syndrome. and a delay in the appearance of reaction timing and equilibrium reactions that may have contributed to delayed development. coordination and timing components of motor control are affected (Seyfort and Spreen 1979).. the infant practices bilateral use of flexion and extension that facilitates strong symmetry. Though the order of the milestones in these developments is generally as such. inferior pincer prehension. speed. Hypotonicity disrupts the feedback mechanism which enables the perception of the position of the body in space. Virji-Babul et al.

1999. Assessment In a child with an intellectual disability.environment and the perception. Push and pull activities related to muscles and joints provide maximum stimulus to this system. goal directed response to a sensory experience" (Ayres 1972b. language and speech pathologist. These measurements can be divided into three groups which assess the measurements of motor functions. the focus is on the assessment of occupational performance. motor. 1979). and leisure).tactile. mild and moderate problems in learning are related to motor in coordination and weak sensory process (Ayres 1972a. and spiritual). and proprioceptive systems (Williamson and Anzalone 2001): Tactile System. Scheerer 1997). Bundy and Fisher 1992. PEDI is a comprehensive test consisting of 197 items used in the assessment of self-care. In Occupational Therapy. occupational therapist. Ottenbacher et al. is a system which receives sensory stimulus from the muscles and joints. The majority of the tests examine both motor functions and daily-life activities (Taggart and Aguilar 2000). perceptual and cognitive skills should be considered comprehensive assessments. Three main sensory systems play a role in the growth and development of the child . WeeFIM® comprises 13 motoric-based daily living skills and 5 cognitive items (Msall et al. cultural) should be assessed (Watson 1992). Two commonly used pediatric functional assessment methods are The Functional Independence Measure for Children (WeeFIM®) and Pediatric Evaluation of Disability Inventory (PEDI). and brain functions integrate with the related systems hierarchically. and environment (physical. Occupational performance areas (self-care. 1992). social. interpretation. one or more measurement results are used in making some decisions about the functional performance of the child (Ottenbacher et al. motor development. activities of daily living (ADL). In all levels of function. Sensory integration theory is based on the view that neural plasticity and sensory integration occur in the developmental order. vestibular. posture. The stimulus of the tactile system is received by the receptors in the skin which is the largest organ of the body. The vestibular system is a system that affects balance. The first is the protective system which informs when touching is harmful. and the other is the discriminative system which informs of the difference between harmful and beneficial touch. Fisher and Bundy 1992. psychologist. and integration of information in order to plan and form organized motor behavior. The following are the occupational therapy tests that can be used specifically in the assessment of mental retardation: . and make developmental assessment. 1994). oral function and nutrition. A multidisciplinary team consisting of a doctor. Ayres 1972c. The proprioceptive system is also important for the development of fine and gross motor muscles. seeing. physiotherapist. 2003b). hearing and intelligence should be assessed (Swaiman 1989). muscle tone and attention. Uyanik et al. physical. In the functional assessment. mobility and social functions of children between 6 to 90 months of age (Haley et al. Vestibular system receptors are within the inner ear and are related to hearing. social worker and special educators will make the best assessment and intervention plan for the child. Vestibular System. provides information about the environment by the sense of touch. The receptors in this system respond both to movement and gravity. sensory integration. Proprioceptive System. The insufficient proprioceptive system also negatively affects motor planning ability. The tactile system has two components. Adaptive motor response is the most significant parameter of sensory integration. 2000. According to this theory. eye movements. "An adaptive response is a purposeful. productivity. sociocultural. performance components (mental.

Ayres 1989. The issues below should be considered in order to plan the intervention: The level of function of the child The developmental status of sensory integration process of the child What are the primary aims of the intervention and what intervention methods should be used with what purpose? How often should the child be treated and what home programs should be given? The intervention program should follow the sequence of motor development seen in typically developing children. Uyanik et al. play and school skills (Troyer 1961). The first stage in enabling the learning of the skills is to direct the child toward the desired goal (Gentile 1992). 1993) for the assessment of cognitive problems Automatic Postural Reactions Tests (Bobath 1990) for the assessment of motor functions Gross Motor Function Measure-GMFM (Russell et al. passive movement and the suitable environment. The assessment of sensory-motor state and environmental adaptations are important in assessing the effect of the intervention. . The assessment consists of the assessment of sensory motor process integration. 1999. Uyanik et al. There are four fundamental principles in the intervention of sensory integration dysfunctions: The intervention process begins with assessment. which is performed prior to sensory integration intervention. Acquiring skills requires the integration of information. 2002. the therapist uses oral stimuli.Loewenstein Occupational Therapy Cognitive Assessment-LOTCA (Itzkovich et al. 2001.1999. 1976. enables analyzing. Ayres 2005). Tural et al. supportive visual stimuli. intervention methods and urgent therapeutic goals. Aki et al. Interventions in Sensory Integration Dysfunctions The fundamental principle in the intervention of sensory integration dysfunctions is enabling planned and controlled sensory stimuli with adaptive responses in order to increase the level of organization of the brain mechanism. The therapist's role in sensory integration programs is to arrange the stimuli coming from the environment so as to enable the individuals to demonstrate appropriate motor behavior. Sensory integration assessment. 2003b. and develop self-care. Ayres stated that sensory integration is significantly related to the development of hearing and language skills besides motor coordination (Ayres 1979).1993) for the assessment of gross motor functions AAMR Adaptive Behavior Scale-School Second Edition (Lambert et al. Düger T et al. the effects of the maturation and behavior process and defining the developmental profile (Dengen 1988. synthesing. 1993) for the assessment of adaptive behavior processes The Pediatric Clinical Tests of Sensory Interaction for Balance (P-CTSIB) (Richardson et al. Bumin et al. Jobling 2006. Russell et al. and interpreting the individual's sensory-perceptual motor behaviors. the positioning of the child. the adaptation process of the individual. When the individual achieves highly controlled behaviors such as running. Uyanik et al. 1992) for the assessment of balance deficits in children Southern California Postrotary Nystagmus Test (SCPNT) (Ayres 1975) for the assessment of vestibular functions Bruininks-Oseretsky Test of Motor Proficiency (BOTMP) (Bruininks 1978) for the assessment of motor skills Southern California Sensory Integration Tests (SCSIT) (Ayres 1972b) for the measurement of sensory perceptual motor performance Sensory Integration and Praxis Tests (Ayres 1989) which consist especially the assessment of praxis and sensory integration Researchers who have used the assessment tests stated above have determined the condition range of children with special needs (Kantner et al. 1998. 2007). 2001. In enabling the child to acquire skills.

slide. It should also be noted that home care for the child provided by parents and family and emotional and social development also play an important role in the intervention. climbing bars). The organization of sensory stimulus which is internalized by the adaptation of the body. skooter board. rhythm bands etc. and I am the hurricane you should try not to fall down" and therapist pushes the child very slowly for couple of times in order to disrupt the child's balance (Kramer 2007). walking in unusual patterns and different surfaces. rolling. and activities which require little muscle movement such as drawing pictures and drawing lines help to develop ocular control. proprioseptive and visual input and feedback Apedal and quadrupedal activities. and reading. Activity training for sensory perceptual –motor dysfunction The appropriate adaptation of the environment is very important in the intervention of sensory integration.hopping. gross postures and patterns of motion (rolling pivot prone. hopping games. The intervention depends on the intersensory integration process. Net hammock and ball activities can help to improve gross motor accommodation and praxis. throwing) Motor planning (praxis): is the ability of the brain to conceive of. skills and interest of the child and the therapist's education (Gilfoyle and Grady 1971. Dengen 1988). Tactile. and carry out a sequence of unfamiliar actions as necessary when learning new skills. The child's success depends on the therapist's communication and coordination with the patient's family and with other disciplines while planning the intervention program. vestibular. running. barrels. an improvement in the assimilation and adaptation process of the visual. relays. vestibular. Activities directed toward goal achievement help to develop motor planning skills. vestibular. Play of boat in the ocean in the quadruped position can facilitate balance and equilibrium reactions. skipping. and the sensory integration process are the main steps of the intervention. Tactile. Integrating intervention activities into the general play of the children in the program can be beneficial. . proprioceptive and vestibular stimuli occurs. Therapists say "you are a boat in the ocean. The following activities are suggested in sensory integration intervention according to the child's proper sequence of development: Tactile. and integrative patterns of different positions can maintain these stimulations. jumping on twister spots. ball playing. proprioseptive input and feedback Righting and equilibrium reactions. Tactile. Specialized programs depend on the age. jumping. ball playing. writing. tactile. function loss. organize. vestibular. all fours. purposeful hand movements appear and the child can cross the midline of his body. follow the leader. proprioseptive input and feedback Gross motor accommodation. bean bag. standing. on elbows. The environment should be interesting to the child. catching. hopping. Bilateral motor coordination: When both sides of the body work together in coordination. crawling. gender. musical games. running. playground equipment( swings. Ocular control: activities which require the movement of hands and large muscle groups such as throwing and catching. proprioseptive and visual input and feedback Activities for bipedal positions.

Good ocular control. Lerner 1985. the cerebellum and the reticular formation have reciprocal associations and affect motor behavior. 1988. The child needs activities which consist of all these components in order to develop fine motor skills. . bilateral motor coordination and tactile sense affect hand functions. 1986. In contrast to children with isolated vestibular pathology. The vestibulonuclear complex. neck and arm muscles is required. Bumin and Kayihan 2001.g nesting cups and graduated pegs) and many constructional tasks (puzzles. 1988). and visual attention skills. Kelly 1989). and that the improvement observed in children in the period following the intervention is continuous because of undeveloped brain plasticity (Ayres 1972a. proprioceptive and visual input and feedback In the learning of fine motor skills. puzzles. pushing. finger plays. appropriate postural stability is important. Ayres stated that. Shumway-Cook 1992). 2003a). The vestibular dysfunction is observed in many developmental disorders as motor discoordination and learning disabilities (Magrun et al. 6. serious problems are observed in the motor sufficiency of children who demonstrate insufficiency in efficiently organizing visual somatosensorial inputs and normal vestibular inputs for postural control. and regulating the level of liveliness (Ottenbacher and Petersen 1983). working against resistance and pressure Visual–Spatial Perception: Children with dysfunctions of visual space perception have difficulty in writing and working with numbers. The vestibular system is particularly important in the development of motor skills. and also in developing inquiring-behavior. carrying heavy objects. block designs. Uyanik et al. Schaaf 1985. vestibuloocular inputs are significant in eye-head coordination which is important for stabilizing the look at one point. MacLean et al.Proprioceptive activities: climbing. Serial activities (e. Learning and understanding direction concepts help to develop visual space perception. the integration of postural reflexes. The vestibular system is one of the first sensory systems that develop prenatally and is functional at birth due to the completion of its structure anatomically (ShumwayCook 1992). Tactile. Also good cocontraction of head. and hammocks (Shumway-Cook 1992). origami. peg boards (Ayres 1979. whereas vestibulospinal inputs are significant in maintaining postural stability with visual and somatosensory inputs (Nashner et al. according to the sensory integration theory. Motor activities such as walking. cranial nerves that enable extra ocular muscle movements and into all spinal levels that affect muscle tone (Ottenbacher and Petersen 1983. Normally. 1981. For example. because motor planning and visual space perception interrelate. Scheerer 1997. running. the effect of vestibular stimulation in the central nervous system stems from the plasticity of the nervous system. Horak et al. It is stated that there is a strong relation between visual perception and motor performance (Brien et al. pulling. 1982). Cohen and Keshner 1989a. 1979). Therapists who treat children with vestibular dysfunction stimulate the vestibular system with equipment such as swings. Motor planning activities and visual space perception games have motor planning components. Activities directed toward vestibular and ocular controls which require knowing the position of objects in space help to develop visual-spatial skills. stair climbing can be structured to encourage a child to attend visually to spatial features (Kramer 2007). scooter boards. Cohen and Keshner 1989b. 4. and graphic copying) can be given as examples to visual– spatial perception. The Role of the Vestibular System in Motor Development The vestibular system is important in the achievement of normal motor development and coordination (Weeks 1979a. forming coordinated eye movements. The vestibular system is one of the wide sensory systems. Shumway-Cook 1992). Wilson 1988. Fibers pass into the vestibulonuclear complex from which they pass into the cerebellum and also into the 3.

1991. but particularly the horizontal position is more important (Ayres 1979. Uyanik et al. There are a number of precautions to consider the vestibular stimulation: As a result of over stimulation. hypotonicity in extensor muscles. The horizontal position and especially the prone position activate otoliths more efficiently than the upright position. Whether the vestibular stimulation has excitatory or inhibitory effects is determined by the form of the stimulation. These are activities which enable active equilibrium on steep surfaces such as stairs. and swing back and forth. Rotational movement and linear acceleration-deceleration stimulate different receptors. and intolerance to movement (Fisher and Bundy 1989). positioning upside down.The following can be beneficial as the therapeutic effects of vestibular stimulation (Weeks 1979b. by moving the support surface. For this. The horizontal position is also the best position for semicircular canal stimulation. glider. 2003c): Developing gross motor functions and reflex integration Regulation functional balance Increasing perception-motor skills Developing hearing-language skills and intellectual functions Increasing socio-emotional development Decreasing self-injurious and/or stereotypical behavior Helping the beginning of intervention by enabling individuals to be more receptive to the different forms of intervention In assessments of determining the indication of the vestibular stimulation intervention. creeping and. the child should be checked for evidence of over stimulation or under stimulation and allowed to determine his own speed. Therefore. Uyanik et al. rhythmic. weakness in equilibrium and support reactions. it is necessary that most of the following findings have positive outcomes: shortening of the post-rotary nystagmus duration. Sandler and McLain 1987. These are: bouncing-jumping activities (whilst sitting. To lessen the fear of movement or positional change by increasing the weak passing of otolith input. inefficiency in pivot prone (prone extension) position. and passive movement has inhibitory effect. linear vestibular stimulation is applied in tolerable speeds and durations and in unthreatening positions (Fisher and Bundy 1989). Kelly 1989). rapid movement has excitatory effect. Dave 1992. Vestibular stimulation intervention methods In the application of vestibular stimulation. decrease in (co-contraction) joint stability. prone and supine positions) other linear activities (jumping or falling onto pillows or mattress in sitting. 2003a. the center of gravity is changed to create disorganization for a short time and thus phasic head movements are made to appear. kneeling. the center of gravity is changed as active or passive. or standing) linear swinging activities (using platform and T-swing. and after vestibular stimulation. In addition. lying prone and supine or side-sitting activate different parts of the canals and otoliths at different degrees. therapy balls and barrel. ramps and unfamiliar surfaces by using equipments such as balance boards. Magrun et al. Different types of sensory stimuli form by rolling. and before. displacement of the center of gravity is created. linear activities are given in accordance with the order of motor development. Arendt et al. during. Slow. sensory overload occurs and this results in organization dysfunctions in the central nervous system. the structure and position of the vestibular stimulus is significant in the efficiency of stimulation. hammock and barrel swinging in kneeling. over stimulating should be avoided. by pushing-pulling activities. Pfaltz 1983. Ayres pointed out that different head positions and movements are necessary for the stimulation of vestibular receptors. prone and supine positions) To development of equilibrium reactions by increasing semicircular canal responses. feeling of gravitational insecurity. . 1981. standing. Types of vestibular stimulation: To normalization of extensor muscle tone by increasing otolith organ input. sitting.

NDT is a popular therapy method within the intervention approaches of infants and children with neuromotor dysfunction (Bobath 1980. technical approaches that were applied manually were utilized less. The intervention is based on this detailed analysis. Sensory stimulation response is different in each child. With functional activity education. The Bobaths recognized that inhibition is a major factor in the control of movement and posture. approaches such as sensory integration intervention. normal postural tonus. NDT has included three basic components related to neuromotor control: Postural tonus Reflexes and reactions Movement patterns One of the primary purposes of NDT is the facilitation of normal muscle tone in order to maintain normal postural and movement patterns. and the outcomes were satisfactory (Bobath and Bobath 1967. Fisher and Bundy 1989). language-cognitive approaches are more effective when used individually or consecutively as may be required (Bobath . 1986. Mayston 1992). neurodevelopmental therapy. hypotonia. the effects of the intervention are increased. In the Bobath method. perceptual-motor intervention. Many studies on the effects of NDT were conducted by Bobaths and other researchers. The NDT approach focuses on the normalization of hyper or hypotonic muscles. or problems in the relation between the central postural control mechanism and coordination need to be defined first. resulting in abnormal postural tone (spasticity. and the child should be checked carefully at this time (MacLean et al. In such an approach. Automatic righting. For automatic and voluntary activities.The over inhibition of the brainstem is the greatest potential harm resulting in seizures. normal reciprocal interaction of the muscles and automatic movement patterns are priorities. and it is customized. and depression in vital functions. disordered reciprocal interaction of muscles (overfixation. lack of grading). it was used in the intervention of many developmental disabilities. In children with hypertonicity. In this approach. researchers have focused on a complex facilitation-inhibition process for many years. vestibular stimulation. the specific handling intervention of equilibrium reactions and the child's movement and its facilitation. Bobath 1980. Neurodevelopmental Therapy Approach The Neurodevelopmental Therapy Approach (NDT) which is one of the most common intervention methods utilized in the intervention of children with developmental dysfunction was first used in the therapy of children with cerebral palsy. play therapy. and analyzed. and a disturbed automatic background of activity on which skills can be performed (Mayston 1992). Harris 1981). In children with developmental problems. Later. because the child's reactions are corrected by the therapist's techniques.1986. Ottenbacher et al. a counter effect in the form of more tone increase may occur. The Bobath method was used with more dynamic and functional approaches in later years. cyanosis. In order to enable the child to control equilibrium reactions and movements by himself. It is considered to be important in the development of selective and graded movement for function. DeGangi et al. Lilly and Powell 1990. equilibrium and protective reactions which were thought to be the basis of functional and voluntary movements began to focus on the facilitation. the child's functional skills are observed. more interaction takes place between the therapist and child with a disability (Mayo 1991). 1983. normal postural reactions. Combined Interventions In studies conducted in the child with an intellectual disability. All upper motor neuron lesions can be described as a disturbance to this mechanism. For this purpose. fluctuating tone). researchers facilitated normal mental and motor development by utilizing different stimulation techniques together. Bobath 1990.

NDT or perceptualmotor training techniques can be used together to facilitate the child's performance (DeGangi et al. the development of proprioceptive feedback is beneficial. perceptual and psychosocial needs and activity components are assessed. In this analysis. cognitive. 1982a. from easy to difficult and only progressing once the skill in the previous step has been accomplished (Gilfoyle and Graddy 1971).and Bobath 1967. the appropriate activities are chosen after determining the level of weakness of integration between the child's response at one level below and top level adaptation behavior. confuse effects which may be caused by other people or the room arrangement are avoided. the intervention should be directed not only by taking the child into the program but also by environmental adaptations that increase the child's functioning and by activities such as play activities that are multipurposeful. the child starts the play activities. 2009). sitting. Bobath 1980. the child is taught how to gain developmental skills. and applying resistance. 1987). and comprised of the easiest possible movement components are chosen. Thus. by giving play activities suitable for NDT techniques. Ayres 1972a. and a safe environment is created in which sensory-motor development can be increased without imposing prohibitions. the environment is organized by arranging the available toys and materials. For this purpose. By increasing visual stimuli besides touch and proprioceptive equilibrium stimuli. and the therapist is the observer and facilitator. the therapist determines the important sections of the activity according to the child's needs and NDT targets. 1993). and how to develop motor functions needed for sensory integration and skill performance. 1982b). Subsequently. to enable appropriate activity experiences that provide stimulus to normal movement patterns and to motivate the child by supporting normal developmental needs within the program. the child's motor. Following the assessment of reflex development. The purpose of the NDT approach used together with play therapy is to develop individual cognitive and perceptive skills. As in approaches applied in Snoezelen or multimodal sensory rooms. In the StructuralDevelopmental intervention approach. the specific NDT instrument is determined according to the child's needs. postural and motor adaptation is aimed to be achieved. Uyanik et al. the child actively participates in the intervention process. play surroundings alternatives are created within the environment. While this intervention is being applied. General principles of combined programs applied on child with an intellectual disability as follows: By taking the children's intelligence into consideration. and equilibrium stimuli. Ayres 1979. the amount of stimulation is adjusted to the tolerance level of the child. and standing positions within the order of development. The program is carried out step-by-step. In the improvement of sensory-perception-motor responses. . From this concept. by performing activity analysis first. By having each child work alone in the same room. Motor responses of the child are aimed to be increased by using methods such as positioning and movement activities. quadruped. activities that are easy to learn. the interaction of human and non-human environmental factors is significant. Jobling 2006). skills and roles are practiced and the child becomes able to discover and integrate sensory information received from the environment by forming meaningful relations with people and objects (Lindquist et al. the therapist enables the child's active participation in daily life activities (Anderson et al. 2003a. The order of normal development is followed in the program. Child-Centered intervention and StructuralDevelopmental intervention terms were defined to be used in the intervention of infants and young children with attention and emotional problems. thus enabling attentiveness and motivation. Bumin and Kayihan 2001. The activities are adapted to supine-prone position. By equipping the therapy room with equipments that provide different sensory stimulations. In addition. and by utilizing touch. or creating a feeling of failure (Uyanik et al. In enabling the child to acquire skills. Therefore. By utilizing each equipment appropriately during programs. In Child-Centered intervention.

movement and other activities Developing more complex play levels Practicing self-care skills Developing perceptual and visual-motor functions which are necessary for learning Transferring skills learned in therapy to the school and home environment (DeGangi et al. strength. and stability The following are the issues to be considered while applying the functional approach (Activities of Daily Living-ADL) in a combined intervention of child-centered activity and structuraldevelopmental intervention respectively: Developing a feeling of interest in performing daily activities and motivation Developing the effort of self-expression by using various activities such as drawing Experiencing learned functions by using daily life devices Developing visual-spatial skills within the environmental setting Developing creative self-expression through play. The aim is to establish a close relationship between the infant and the family and start developing independence in occupational performance areas in developmental milestones.DeGangi et al. artistic activity. and postural adaptation. and seek professional help (Ayres 2005) . and developing the plan Organizing motor movement patterns according to activity requirements Increasing tactile-proprioceptive and vestibular sensory inputs which are formed in daily activities Practicing postural control and balance Putting bilateral integration components in order and teaching of their patterns Teaching of motor planning components with the external direction of the therapist Enabling the acceptance of sensory stimulation under the direction of the therapist and enabling this to be used Observing and controlling behavioral responses to sensory inputs The following are the issues to be considered while applying the neurodevelopmental therapy approach in a combined intervention of child-centered activity and structural-developmental intervention respectively: Creating motivation for movement and starting the movement Self-generation of the planned activities Detailed planning of body movements in space Practicing motor movements in play schemas Putting motor movements in order. 1993). It is important that the family is aware of the help they can get from the professionals and the areas of learning in which the infant needs stimulation. Ayres stated that there are five important things that parents can do: recognize the problem so that they will know what their child needs help their child to feel good about himself control his environment help him learn how to play. timing. Family Education To help develop the potential of the child. and planning Satisfaction in motor activities Developing posture and movement components Practicing real-skill performance Eye-hand coordination Equilibrium. 1993 stated that the following are the issues to be considered while applying the sensory-motor approach in a combined intervention of child-centered activity and structuraldevelopmental intervention respectively: Behaviors and searching for the sensory stimulation that is needed for the self-organization of attention and motor movements Forming the idea of motor movement in the general concept of play. education and rehabilitation programs should be initiated in the neonatal period.

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