Newborn & Infant Nursing Reviews 13 (2013) 35–41

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Newborn & Infant Nursing Reviews

journal homepage: www.nainr.com

Enhancing Motor Development in Infants and Toddlers: A Multidisciplinary Process

for Creating Parent Education Materials
Susan E. McMahon, PT, DPT, PCS ⁎
Pediatric Clinical Supervisor, Kaiser Rehabilitation Services, The Permanente Medical Group, 1600 Eureka Road, Roseville, CA 95661

a r t i c l e i n f o a b s t r a c t

Keywords: Pediatric therapists teach parents how to promote optimal movement to infants and toddlers with
Parent developmental delay. Current parent education resources for teaching motor development are dated and
Education inconsistent with modern family centered care practice. The project was designed to develop an original
Infant
series of parent education materials for infants and toddlers with developmental delay due to prematurity,
Motor
abnormal tone, or generalized weakness. A comprehensive literature search was performed to determine the
Development
best method for teaching parents prior to designing a parent education program. Content experts in patient
education and neurodevelopmental therapy assisted in designing the materials. Updated parent education
materials that are consistent with modern family centered care practice were developed. Therapists within
the Kaiser Permanente health care system can use the copyrighted parent education materials available
online, and presented in this project, to assist families in becoming confident and self-reliant when working
on motor development at home. Empowering the patient and family toward directed self-care is critical for
achieving best outcomes for children with developmental delays.
© 2013 Elsevier Inc. All rights reserved.

Physical and occupational therapy for infants and toddlers requires
a strong and trusting partnership with parents to achieve optimal
outcomes. Treatment sessions ideally include home instructions to
help families remember and apply the movement lessons between
clinic visits. Published resources available for reproduction are dated,
costly, and inconsistent with modern patient education and family-
centered care policies.
Current adult education literature indicates that the “major
purpose of patient teaching and learning is to increase the patient's
competence to manage his or her own health requirements.” 1 This
study presents a family education project reinforcing the idea that
parents of children with developmental delay can effectively learn
how to play and work with their children at home to enhance
functional movement and motor development. Therapy for gross
motor delay generally involves parent observation and participation
in treatment activities. Verbal instruction, demonstration, and hands-
on practice of exercises are combined with clear photo illustrations in
this patient education series.
The purpose of this paper is to illustrate the multidisciplinary
process of creating a series of parent education materials to promote
⁎ Address correspondence to Susan E. McMahon, Pediatric Clinical Supervisor, Kaiser
Rehabilitation Services, The Permanente Medical Group, 1600 Eureka Road, Roseville,
CA 95661.
E-mail address: smcmahon55@aol.com.
developmental skills in infants and toddlers with developmental
delay due to prematurity, abnormal tone, or generalized weakness.
The materials include photographs of infants and toddlers receiving
physical therapy for disorders of posture and movement. The
activities are designed to be playful and easy to learn. The written
instructions use simple language and are designed to be helpful for
parents of all educational levels. The finished handouts are designed
to be used concurrently with ongoing clinic-based treatment.
The completed project includes free online access to the copy-
righted educational materials though the secure Kaiser Permanente
corporate website. Parents, physical therapists, occupational thera-
pists, and primary care providers employed or served by the medical
corporation will be able to download and print the exercises and
activities. The finished product includes a variety of helpful tools and
techniques for professional use when designing home programs for
families of children with developmental delays. The discipline of
defining our process, as well as sharing the finished product, can
empower pediatric and neonatal therapists to design effective home
programs at other treatment sites.
Optimal growth, development and learning through movement
are enhanced by providing families with useful resources to
complement clinic based physical and occupational therapy
services. Improved quality and accessibility of parent education
materials contributes to best practice in pediatric physical and
occupational therapy, ultimately empowering parents and children
at home.

1527-3369/1301-0491$36.00/0 – see front matter © 2013 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1053/j.nainr.2012.12.001
36 S.E. McMahon / Newborn & Infant Nursing Reviews 13 (2013) 35–41

Table 1
Comparison Table of Studies

Reference Subjects Design Instruments and tests

Scales et al 20072 23 parents of developmentally RCT involving parent perception of direct versus Data analysis with chi squared test for home visit rating form.
delayed children instructional therapy approach. Two tailed paired t-test to compare direct vs instructional approach.
Fisher exact test to see if parent educational level affected responses.

Dusing et al 13 parents of infants in the Qualitative pilot study through focus groups Parent report of preferences of 3 methods of teaching; brochure,
20083 NICU lecture and video.
McIntyre 20084 44 families with preschool RCT to evaluate parent training intervention for Post intervention test
children with delays behavioral problems. t Test for parametric data
Chi squared test for categorical data.

Majneemer and 71 4-month-old infants and Cross sectional observational study of the effect Multiple logistic regression analysis,
Barr 2005 50 6-month-old infants of infant positioning on development Pearson rank correlation coefficient and multiple linear regression,
AIMS and PDMS.
Hickman, McCoy, Children with motor concerns Presents an original alternative practice model Not discussed
Rauh 20115 for early intervention.
Ideishi et al 2010 50 adults working in early Community participatory action research using Constant comparative analysis using qualitative coding procedures
intervention questionnaires and focus groups

Blauw-Hospers and Babies aged 0–18 months SR of 34 studies on the effectiveness of early Interrater agreement calculated for methodological quality of
Hadders-Algra intervention on motor development each study
20056
Reithmuller 17 studies on promoting SR involving comparison of design, Search strategy, keywords and databases indicate likeliness
et al 20097 motor development in methodology, intervention, efficacy and that no relevant studies were missed.
young children met alignment with CONSORT⁎ and TREND† Inclusion and exclusion criteria are described.
inclusion criteria
Dunst and 2948 parents of children SR of a battery of scales using meta-analysis
8
Trivette 2009 with average age of 3. structural equation modeling - MASEM‡

AIMS, Alberta infant motor scale; CFI, Comparative fit index; PDMS, Peabody developmental motor scales; RCT, Randomized controlled trial; RMSEA, Root mean square error
of approximation.
⁎Reliability
Definition and
of validity
CONSORT: of tools Results Trials. “The CONSORT Statement is intended to improve
Consolidated Standard of Reporting Level of
the reporting of a randomized controlled trial (RCT),
P values and interpretation, and to assess the validity of itsEvidence
enabling readers to understand a trial's design, conduct, analysis results. It Relevance
emphasizestothat
project
this can only be achieved through
complete transparency from authors.” Retrieved on March 4, 2011 from http://www.consort-statement.org/consort-statement/.
† Definition of TREND: Transparent Reporting of Evaluation with Nonrandomized Designs. “The TREND statement is a 22-item checklist specifically developed to guide
standardized reporting of nonrandomized controlled trials. The TREND statement complements the widely adopted Consolidated Standards of Reporting Trials (CONSORT)
statement developed for randomized controlled trials.” Retrieved on 3/4/11 from http://www.cdc.gov/trendstatement/.
‡ Definition of MASEM: “Uses data from different studies and combines the data to produce a pooled correlation or covariance matrix, where the pooled matrix is used to test an
structural equation model (SEM); Int J Pediatr. 2009; 2009:576840.
§ CFI ranges from 0 to 1, where a value of 0.90 or higher is considered an index of acceptable fit to the data. The closer the CFI is to 100, the better the fit.
‖ RMSEA ranges from zero to 1, where a value of 0.05 or less is considered a good fit. The closer the RMSEA is to zero, the better the fit. Int J Pediatr. 2009; 2009:576840.

Phase 1: Literature Review
Infants and toddlers with developmental delay benefit from physical
and occupational therapy to learn motor skills. Therapy ideally involves a
combination of direct handling and parent teaching for home reinforce-
ment of concepts and skills achieved during the clinic session. The
clinical question for this literature review addresses the need to discern
the best methods for teaching infant motor skills to parents. Initial efforts
focused on review of the relevant literature and determining best
evidence as outlined in the comparative table of resources.
Clinical Question
For parents of infants and toddlers receiving physical therapy for
motor delay, what is the best method for teaching home exercises and
activities to promote improved motor development?
Search Strategy
A comprehensive literature search was initiated using PubMed
Clinical Queries, set for therapy and broad, using key words “parent
education AND physical therapy AND children”. Limits were set at 5
years and all children 0–18 years old. This search yielded 66 clinical
studies and 12 systematic reviews. Five resources were chosen for
further review.
Subsequent searches were performed on PubMed, using several
sets of new key words, including “home program AND physical
therapy AND children”, “parent teaching AND physical therapy AND
children”, “parent AND developmental delay AND teaching”, and
finally “motor delays AND home activities”. The additional 4 searches
yielded over 100 studies with 7 additional relevant studies chosen for
further review.
A final search using OVID search engine, key words “parent
education AND developmental delay AND physical therapy, no
limits, yielded 18 additional studies. Two studies were chosen for
further review. The Ovid database tool for finding similar or related
studies yielded 6 additional relevant sources with 2 chosen for
further review.
The completed literature search resulted in a total of twenty relevant
studies. The best 9 studies are briefly reviewed in the discussion section
and represented in the summary table of resources (Table 1).
Discussion
The learning style and preferences of parents must be addressed
for successful follow through of any home education program for
children with motor delays. In her book, Dreeban 1 stated that
 S.E. McMahon / Newborn & Infant Nursing Reviews 13 (2013) 35–41 37

Reliability and validity of tools Results Level of

P values Evidence Relevance to project

Randomized? Yes. Instructional approach was favored over direct. 1b Supports developing a parent teaching tool for
Groups Similar at start? Yes. Most helpful to parents, .001 children with developmental delay.
Groups treated equally? Yes. Parent learned more, .002 Contradicts earlier evidence that parents perceived
Blinded? More fun for child and parent, .0222 a direct therapy approach as more beneficial.
Yes.
Test was created for this study, reliability not Post intervention test scores improved from 36% to 81% 4 Pilot study indicates that parents prefer a
available. after educational intervention. combination of methods of teaching.
Randomized? Total problem scores showed a significant difference, 1b Parent training and attendance at training sessions
Yes P = .03 1 resulted in significant improvement in overall
Groups similar at start? Yes behavior problems.
Groups treated equally? Yes
Blinded? Yes
r2 = 0.22 for 4-month-olds. P = .007 for 4-month-olds 2b Discussion and recommendations of the importance
r2 = 0.59 for 6-month-olds. P = .0002 for 6-month-olds of positioning and parent education on early infant
Therapists as assessors were blinded. development.
Not applicable Not applicable 5 Expert opinion presenting a new model for early
intervention practice grounded in ICF model.
Interrater reliability established with κ statistic, κ = 0.85 or 85% agreement. 4 Qualitative analysis discussing barriers and
facilitation of care coordination in
early intervention.
Cohen κ was high: Not available 1a Review of high quality studies of various methods
Validity = 0.86 and 0.95 of early intervention for infants in the NICU,
Level of evidence = 0.94 age 0–9 mo and 9–18 mo
Standardized, varied tools for measuring motor skills 9 of the studies show improved motor development. 3 Parents involved in only 3 studies for promoting
were used in comparing the studies. Eight of these reported statistical significance. 2a motor development in young children.
Demonstrates an educational model of
motor learning.
CFI = 0.91§ Family centered care had a direct effect on parents, 1a Pediatric physical therapists working within family
RMSEA = 0.09‖ P b .05 and child psychological health. P b .01 centered care practices can affect parent/child
psychological health.

“successful patient education occurs when health care providers
affirm the presence and validity of diverse learning styles and
maximize the conditions for using instructional designs that best fit
the patients learning style(s)”. Dreeban goes on to state that learning
is a process rather than an outcome, involving the patient's feelings,
thoughts and individual cognitive abilities.
David Kolb's Cycle of Learning 1 is an illustration of the 4
experiential learning cycles including feeling, watching, thinking,
and doing. He noted that “when learners are able to approach all 4
learning cycles, they are experiencing the full cycle of learning.” A
pilot study of the learning preferences of parents with children in the
neonatal intensive care unit demonstrates that parents of infants who
were born preterm benefit from education using multiple approaches.
Dusing and associates 2 reported that parents prefer to learn about
their infant's motor development through a combination of observa-
tion, discussion, and written material. Although the Dusing study does
not directly address teaching motor learning at home, the concept of
multiple forms of learning can be applied to home education. The
study of Dusing and associates also supports the concept of the full
cycle of learning through varied methods of teaching.
A recent study by Scales et al 3 describes parents’ perception of
the benefits of a direct therapy approach compared to an
instructional approach. This study indicates that although parents
perceive the instructional approach to be more stressful than direct
intervention, they also perceive it to be more beneficial for
promoting development. The authors reported that parents prefer
multiple methods of education. In this study, most families preferred
the therapist showing parents how to assist their child during play
activity rather than simply observing the therapist performing the
intervention. The Scales et al study contradicted earlier studies
reporting parent perception of direct intervention as more beneficial
than other approaches. 2
Infants and young children with developmental delays and
disabilities frequently have associated behavioral problems that can
impact the parent-child bonding process. A 2008 randomized
controlled trial specifically investigated the effects of parent training
on parent-child interactions and negative behaviors. McIntyre 4
showed that parent training intervention for children with special
needs results in reducing negative parent child interactions and child
behavior problems. Although this study does not address motor
delays, the concept and results can be related to motor teaching
and reinforcing positive behaviors and parent-child bonding. The
author goes on to note “interventions that assist parents with
developing positive parent-child interactions…may be one ap-
proach to mitigate…behavior disorder…in young children with
developmental disabilities.”
According to a recent review by Hickman and colleagues5 discussing
neuronal firing as it relates to task performance, a rewarding learning
38 S.E. McMahon / Newborn & Infant Nursing Reviews 13 (2013) 35–41

experience for both the parent and child can enhance brain develop-
ment. The authors note that the goals of intervention must be
meaningful to the family in order to achieve the frequency of task-
specific practice required for effective motor learning.
The design of the parent education home program includes
specific reference to neurodevelopmental therapy theories of move-
ment and development. Interestingly, the Blauw-Hospers’ systematic
review indicates that neurodevelopmental therapy is not shown to
have a beneficial effect on development for people with cerebral
palsy. On a positive note, the authors also report that “substantial
evidence has been provided which suggests that specific develop-
mental training and general development programs in which parents
learn how to promote infant development can produce a positive
effect on motor development.”
A 2009 systematic review of studies that focused on interventions
to improve motor development in preschool children was performed
by Reithmuller and colleagues. 7 Of the 17 studies in the review, only
3 included parents. The remaining studies were conducted in
preschool settings without the input of parents. The authors
conclude that promoting physical activity during the preschool
years is important for the development of motor skills. They also
note that physicians and other health care professionals can be
influential in involving parents in motor development interventions, Fig 1. Therapist demonstration of home exercise for learning to sit.
stating “parental involvement is a key element for habitual and
lifelong motor skill development.”
In their systematic review, Dunst and Trivette 8 discuss the positive Identify Hospital Standards/Expectations for Appearance and Language
influence of family centered care on the physical and psychological
health of the parents and the child. 4 The study results demonstrated Signed consent for photos was obtained for all participants and
that “Family centered care had indirect effects on parent and child scanned into the electronic medical record. Photos were taken by either
psychological health mediated by self-efficacy beliefs.” the therapist or the parent. Corporate-approved patient education
In summary, the literature reviewed for this project supports the templates were used to create the finished materials. Language and
important concept that pediatric physical and occupational thera- content were reviewed and approved by the rehabilitation publications
pists working within family centered care practices can positively committee after several revisions for clarity and conciseness.
affect parent-child psychological health and development. This study
illustrates a successful process of creating effective tools to provide Utilize Outside Experts for Content
parents with current, easily accessible and helpful home education
materials for motor learning as part of a comprehensive rehabilita- Utilizing an expert in Web design and creation of printed patient
tion program. education materials was helpful in reviewing the planned layout and
content prior to creating the documents. An information technology
consultant assisted in revising the therapist website to reflect new
Phase 2: Collaborative Team Process additions and content. Plans included design for the future addition of

Identify the Problem

The need for this project was initially identified when parents and
staff therapists consistently reported difficulty with parent under-
standing and carryover of suggested home activities. Putting together
effective individualized home programs took time away from valuable
one-on-one patient care time. Therapists needed quick access to
attractive and easily understandable materials to give to parents
during treatment sessions.

Gather a Multidisciplinary Team

Consultation with peers, classmates, expert consultants, and

parents in 2010 and 2011 helped with planning the content of the
proposed educational materials. Additional consultation with an
experienced clinical instructor and neurodevelopmental treatment
expert provided insight into the theory and rationale behind choosing
appropriate movement strategies for home teaching.
Families of infants and young children aged zero to 36 months
from the outpatient physical therapy clinic were presented with the
concept of creating new patient education materials and invited to
participate. In addition, family and friends were solicited for photos of
typically developing infants. Fig 2. Parent participation and demonstration of home exercise for tummy time.
 S.E. McMahon / Newborn & Infant Nursing Reviews 13 (2013) 35–41 39

Developmental Activities at Home

For the NICU Graduate

How can I help my premature baby with development at home?

Premature babies often need a little extra help and practice at home to learn the basic skills for early
development. You may find that your baby is extra strong in arching and straightening her legs. She may dislike
lying on her tummy or being in a curled position.

When your baby is very tiny, tummy time with you is a nice way to help her relax. Early tummy time can be
started as soon as you go home. Never leave your infant unattended on her belly. And, of course, always put her
to sleep on her back.

Time tucked in your lap, looking at you and listening to your voice is relaxing and fun for both of you!

Rehabilitation/Physical Therapy Department

Fig 3. Sample front page of parent education program for NICU graduates.

links to provide patient access to the education materials. The regional
Director of Rehabilitation Services assisted with placing the educa-
tional materials on the department shared drive.
Separate parent and professional short questionnaires were
created to assess the effectiveness of the newly designed educational
materials. Learning preferences for both parents and profes-
sionals were briefly addressed in the questionnaires to provide
insight for future projects. Individual interviews and team
meetings were conducted with pediatric therapists and neonatal
intensive care nurses.
40 S.E. McMahon / Newborn & Infant Nursing Reviews 13 (2013) 35–41

These photos illustrate simple play positions

that are helpful for your newborn premature
infant.

Lifting and carrying in a tucked and flexed position can help with decreasing the leg and back stiffness that is
common with preemies. Side lying and reaching for toys at eye level are also good play positions.

Have fun with your baby; keep the play sessions short and frequent. Several minutes each session, three to
five times a day is a good minimum guideline. Your baby will let you know if she is tired or unhappy.

This information is not intended to diagnose health problems or to take the place of medical advice or care you receive
from your physician or other health care professional. If you have persistent health problems, or if you have additional
questions, please consult your doctor.

(c) January 2010 all rights reserved

Rehabilitation / Physical Therapy Department.

Fig 4. Sample back page of parent education program for NICU graduates.

Project Phases of Development
The initial phase of the project describes common early infant
interventions for normal development. These handouts were ap-
proved by the corporate regional publications committee in 2010. The
first series of parent education handouts are the original work of this
author and are available to patients and professionals for free in print
and in PDF versions through the secure Web sites throughout the
Kaiser Permanente multi-state health care system.
Once the initial series illustrating normal development was
available, therapists and parents requested additional materials to
illustrate treatment strategies for atypical development. The desire to
 S.E. McMahon / Newborn & Infant Nursing Reviews 13 (2013) 35–41
create materials that were consistent with current evidence based
care generated the detailed literature search for the second series.
A third phase was initiated when neonatal nurses requested
Neonatal Intensive Care Specific (NICU)–specific parent education
materials to enhance parenting and infant development during the
prolonged hospital stay. This phase was created with our Roseville
Women and Children's Hospital Care Neonatal Developmental Team,
consisting of a clinical nurse specialist, skilled bedside nurses, and
neonatal therapists. The language and design of the third series of
materials followed the guidelines in the first 2 for parent friendliness,
simple language and photography. The book Preemie, 9 newly
published by Kasey Mathews in May 2012, describes a young mother's
experience in the NICU. Her description of her overwhelming
experience in the nursery influenced the final simple design and
language of the NICU series.
Complete the Creative Work
This project stalled several times since the initial need was
identified in 2009. Several blocks to completion included high patient
caseloads and difficulty finding time to take and edit attractive photos.
Multiple editing revisions required additional time. Identifying a team
leader who was held accountable by the group to finish the project
was essential. This author created the documents after receiving
training with the information technology consultant and content
experts. The team members assisted with providing patients, taking
photos, and reviewing and editing multiple revisions for all 3 series.
A total of 31 home programs for parent teaching were produced
and approved for regional use. Topics on therapy ball activities, rolling
and sitting transitions, quadruped and kneeling transitions, standing
preparation, exercises for idiopathic toe walking, standing balance,
jumping, and stair climbing were completed. Additional topics include
activities and positioning for right and left torticollis, tummy time
activities, home activities for the NICU graduate, learning to sit, stand,
crawl, and walk. These topics represent the home programs most
frequently requested by the pediatric therapists who were initially
interviewed for this project. The neonatal project consisted of weekly
phases of development describing what to expect and how to help.
Families and therapists were provided with an opportunity to
review and provide feedback for the series. The educational review
experts provided feedback and minor editing recommendations.
Subsequent changes in 4 separate drafts were completed after
feedback from all sources. Final documents for the first 2 phases
were sent to the print shop and placed on the corporate shared drive
for all therapists to use in April 2011. Online patient access will not be
available until completion of a pending large website revision for
patient online services. A total of 21 educational handouts for
pediatric therapy are now available online and in print for use with
patients within the multi-state health care system. The additional ten
NICU parent education brochures discussing parent involvement in
developmental care will be available in fall 2012.
Discussion
Therapeutic intervention for infants and children must be viewed
from a family centered perspective. The days of treating infants and
children with developmental delays behind closed doors with parents
anxiously sitting in the waiting room are gone. In order to form useful
goals for children, the therapist must skillfully discern the functional
skills that are most important to both the child and the family.
41
The pediatric therapist must view the parents and child as the
most important team members, listening and empowering them
toward the change they desire. The pediatric therapist can view their
professional function as that of a facilitator or teacher for the family,
using therapeutic skills, technique, and clinical experience to assist
the family and child in achieving their goals.
Therapists can use the parent education materials presented in this
project to assist families in becoming confident and self-reliant with
learning and working on motor development at home. Empowering
the patient and family toward directed self-care is necessary in our
current health care environment of restricted utilization. The
materials cannot replace clinic-based therapy and are designed to
be used as an adjunct to direct care services. A simple handout, no
matter how well designed, cannot replace face-to-face teaching and
practice. Fathers and mothers are illustrated in the home activities,
indicating through example that everyone in the family can
participate in the joy of teaching and learning movement. (See
Figs 1 and 2.)
Pediatric physical therapists have a vital role in assisting families
and children with developmental delays. Therapists must be sensitive
to individual patient and family educational levels with learning
techniques to enhance motor development skills. Actively involving
parents in every step of physical rehabilitation and empowering them
to become confident and proficient in helping their child at home
benefits the entire family.
Conclusion
Creating anything new requires multiple phases of development.
Innovative projects can easily get stuck at any stage. With busy
schedules and multiple demands placed on pediatric caregivers, it is
easy to quit or put projects on indefinite hold. Perseverance and
decisiveness is required to bring valuable projects to completion. A
good project needs a team leader who takes responsibility. A good
team leader needs a dedicated and supportive team to hold the leader
accountable for bringing the project to completion. An effective
process for quality work must be in place prior to initiating the work
to do the job well. It is vital that new ideas for improving therapeutic
intervention be multidisciplinary and evidence based. (See Figs 1–4).
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