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Effectiveness of the Test of Infant Motor Performance as an Educational Tool for Mothers

Goldstein, Lou Ann PT, MS, PCS; Campbell, Suzann K. PT, PhD, FAPTA

doi: 10.1097/PEP.0b013e3181729de8
Research Report

Purpose: To determine if the Test of Infant Motor Performance (TIMP) could be used as an educational tool for mothers; if learning is dependent on the format used or the tester; and if mothers could retain information provided on motor development of infants born prematurely over a short period of time.

Method: Twenty-eight mother-infant pairs were assigned to either a pictorial format group or a text-only format group. Mothers completed a survey before and after observing 1 of 2 therapists perform the TIMP on their infant.

Results: A 2-way analysis of variance showed a significant improvement in the mother’s survey scores from the pretest to the post-test (p < 0.0001). Tester and format did not produced significant differences in mother’s scores. On a follow-up telephone call 91% recalled activities to help their infant’s development.

Conclusion: The TIMP was shown to be effective for educating mothers about infant motor development.

This study demonstrates how the TIMP can be used as an effective educational tool to teach mothers about infant motor development.

Physical Therapy Department, University of Illinois at Chicago, Chicago, Illinois

Additional material related to this article can be found on the Pediatric Physical Therapy Web site. Go to www.pedpt.com.

Address correspondence to: Lou Ann Goldstein, PT, MS, PCS, University of Chicago Medical Center, Therapy Services MC 1081, 5841 South Maryland Avenue, Chicago, IL 60637. E-mail: LouAnn.Goldstein@uchospitals.edu

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INTRODUCTION

Developmental delay is prevalent among infants with very low birth weights (VLBW, less than 1500 grams) as a result of increased biological and environmental risks.1,2 With the addition of comorbidities, such as chronic lung disease and brain injury, the overall rate of cerebral palsy is 13% to 15%.3 In addition, infants from low socioeconomic status (SES) and disadvantaged environments are more likely to have developmental deficits.1 These infants are usually eligible for early intervention services under Part C of the Individuals with Disabilities Education Act (PL 108.446).4 Parent education is an essential aspect of early intervention for infants with high risks for impaired development. According to the Guide to Physical Therapist Practice, “Educating is the process of imparting information or skills and instructing by precept, example, and experience so that individuals can acquire knowledge, master skills, or develop competence”.5 (p. 41) To create an effective educational program focusing on infant development for parents of infants who are at high risk, therapists should select a teaching tool or method that most effectively communicates the infant’s current function and gives the parents knowledge of what to expect in the future.

One tool used to test infant motor behavior and educate parents about their infant’s function is the Test of Infant Motor Performance (TIMP).6 The TIMP is an assessment of posture and movement of infants from 34 weeks postmenstrual age through 4 months corrected age.7 In an effort to make the TIMP an appealing test for parents to observe and learn from, the test developers added photos of infants to the items on the original text-only test form (V.3).8 Using the pictorial format of the TIMP (V.5) along with the therapist’s knowledge and guidance, the parents can match the infant’s performance with that of babies shown on the test form. This format also provides pictures of the next steps to achieving a more mature response in a task to provide anticipatory guidance to parents regarding expected future performance. Although using the TIMP pictorial format would appear to be an ideal teaching tool to educate parents on motor development in young infants, this premise has not been tested.

The purpose of this study was to evaluate the effectiveness of the TIMP as an educational tool for mothers and to compare the effectiveness of the two formats: text only or pictorial.

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REVIEW OF RELATED LITERATURE

Parent education is important to infant development because it has been shown to encourage parent-infant relationships, helps parents learn typical developmental trends such as when infants should sit by themselves, and helps parents identify when delays may be present. Research has documented that parent involvement in the examination process facilitates parent-infant relationships. Widmayer et al9 demonstrated that the Brazelton Neonatal Behavioral Assessment Scale10 is an effective method of fostering the mothers’ responsiveness to her infant’s behaviors. Unanue11 compared 2 types of parent education programs (family-centered parent education vs general education on infant development) and, although she did not find a significant difference between the programs in terms of infant outcomes, she reported that both programs increased the parent’s confidence levels in caregiving and slightly improved caregiving abilities. Brown et al12 studied the effectiveness of a year long, at-home video course on infant development. Results from midyear and year-end of The Knowledge of Infant Development Scale13 data revealed that the mothers who took the course gained significantly more knowledge about infant development and mothers of preterm infants learned more when compared with mothers of infants born full-term. Melnek et al14 found their educational-behavioral intervention program provided to mothers of low birth weight premature infants while in the Neonatal Intensive Care Unit (NICU) produced significantly higher scores on the Mental Developmental Index of the Bayley Scales of Infant Development15 at 3 months and 6 months corrected age as compared with the control infants. Brazelton et al16 used the Neonatal Behavioral Assessment Inventory to acquaint parents with their newborn’s behavior and improve their knowledge and awareness of their infant’s abilities. It may be inferred that parent education on infant motor behavior may be as beneficial to development in the motor sphere.

Parent education has also been shown to improve the parent’s ability to provide a stimulating environment for infants. Parker et al17 examined the efficacy of developmental intervention in the NICU for mothers of infants born preterm with low SES. The intervention sessions were held weekly with the mothers. Follow-up home visits at 4 and 8 months of age showed that the experimental group scored significantly higher on the Mental Developmental Index of the Bayley Scales of Infant Development18 at both ages, and significantly higher on the Motor Scale, but only at 4 months of age. The authors suggested that their results supported the benefits of educating parents in infant development.

Using pictorial and written formats in patient and parent education has been well-accepted in educational and medical literature.19–21 Reed et al21 studied the effectiveness of using pictorial cues to enhance an individual’s recall of information. The subjects were found to have better recall with the illustrations as compared with written stimuli alone. Lloyd et al20 examined the effectiveness of using discharge information sheets emphasizing the importance of risk factors and a follow-up therapy with patients diagnosed with significant coronary artery disease. Patients who received written information were more aware of their blood pressure and drug therapies and were better able to remember the pictorial “map of the heart” showing the extent of their coronary disease. Further support for using pictorial illustrations in parent education was provided by Feldman et al19 who examined the effectiveness of using pictured books as self-learning devices to teach child-care skills to a convenience sample of 10 parents with intellectual disabilities. The results showed that self-instruction pictorial parenting manuals were effective in teaching child-care skills to these mothers.

In summary, the use of pictorial formats in patient and parent education has been shown to be effective when compared with written or verbal instruction alone. Although research supports the use of parent education in infant development, no research exists using a developmental assessment tool as an effective method for educating parents on infant motor development.

The authors hypothesized that the TIMP would be an effective educational tool for mothers and that mothers would recall more information about infant motor function immediately after observing the examination using the pictorial format of the TIMP regardless of the tester involved and that similar expectations would hold regarding the mother’s ability to recall what she had been taught 3 to 5 days later.

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METHODOLOGY

Participants

The subjects in the study were mother-infant pairs recruited as a convenience sample from a clinic in an inner-city hospital primarily serving African American families of low SES. The clinic is designed to monitor infants born preterm and full-term at risk for developmental delays. Ninety-one percent of the infants seen in the clinic have VLBW. As of April 2006, the clinic population consisted of 162 infants distributed among 3 racial groups: 2% white, 88% black, and 6% Hispanic. Subject recruitment methods were approved by the Institutional Review Board for the protection of the rights of human subjects. The sample included 28 mother-infant pairs. Tables 1–3 describe the characteristics of the infants. Four sets of twins participated in the study. In each case, only one of the twins was tested. The other twin was still hospitalized and was not present during the clinic visit. All mothers were African American. Mothers of VLBW infants were chosen because of the infant’s increased risk of future developmental deficits and the mother’s need to recognize potential delays. Although subjects were not excluded based on race or ethnicity, no eligible mothers of any other race or ethnicity attended the clinic during the study period. The exclusion criteria for this study were (1) mothers familiar with the TIMP or who have observed a therapist perform the TIMP on their infant prior to the clinic visit; (2) mothers less than 18 years of age, and (3) mothers who presented to clinic with other children who required adult supervision. The latter were excluded because of the possibility that the presence of other children would influence the learning environment. Criteria for inclusion in the study were mothers with legal guardianship of an infant born preterm born with a birth weight of less than 1500 g.

TABLE 1

TABLE 1

TABLE 2

TABLE 2

TABLE 3

TABLE 3

The infants were between the ages of 36 weeks postmenstrual age and 6 weeks post-term at the time of testing. The age range was chosen based on the typical age of the infants when they attend their first clinic visit. Furthermore, the age was chosen to limit the number of developmental skill possibilities seen in an infant at one particular time.

The assignment of the mother-infant pairs began with a random assignment to either the control group (text-only format) or the experimental group (pictorial format) using the last digit of the infant’s medical history number. Odd numbered pairs were assigned to the control group (text-only format). Even numbered pairs were assigned to the experimental group (pictorial format) (Table 4). During the study, an uneven number of subjects were enrolled into the text-only group. To even out the groups, the last 4 subjects were assigned to the pictorial format group. Thus, completely random assignment was not maintained.

TABLE 4

TABLE 4

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Instrumentation

The written (V.3) and pictorial (V.5) formats of the TIMP were the instruments used to facilitate the mother’s ability to understand infant motor performance.22 The TIMP has construct validity as a measure of motor performance in infancy from 34 weeks postmenstrual age to 4 months corrected age.7 The TIMP has been shown to measure age-related differences in motor skills as shown by a significant relationship between postmenstrual age and TIMP performance (0.83).23 The TIMP may be an effective tool to teach parents about motor development because the infant’s performance is scored based on a caregiver-focused, pictorial format. The TIMP identifies infants who have motor deficits and which infants will be likely to benefit from early intervention in the NICU following discharge.22 The TIMP discriminates motor performance among infants of differing risk levels.24 The TIMP has a sensitivity of 92% and a negative predictive value of 98% for predicting 12-month performance at 3 months of age.6 The TIMP has also been shown to have ecological validity because 98% of the elicited items on the TIMP match environmental demands placed on children by their caregiver.25

The dependent variable for measuring parent knowledge of motor development was the mother’s gain scores on the Premature Baby Motor Survey (PBMS). The PBMS is an author-designed multiple-choice questionnaire constructed based on the theoretical concepts of the TIMP. The PBMS contains 10 multiple-choice questions and 1 open-ended question asking the mothers to recall activities the therapist taught them. The activities were designed to be performed by the mother with her infant to promote motor development (Appendix A, which is available at www.pedpt.com). The text of the PBMS was rated to be at the seventh grade reading level for US students (7.7 grade level) using the Flesch-Kincaid Grade Level from Microsoft 2003. Pilot work was completed on the PBMS to examine whether the questions were understandable to mothers. A group of special education teachers, physical and occupational therapists, and 1 nurse provided comments on question structure, variety, content, readability, and terminology. The survey was also pilot tested with a group of African American mothers to assess the mother’s ability to read and complete the survey. A telephone survey was also developed and used to measure the mother’s ability to recall the information taught during the therapy session (Appendix B, which is available at www.pedpt.com). The questions on the telephone survey were taken directly from the PBMS, including 3 multiple-choice items, (3, 6, and 8) and the open-ended question.

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Procedure

The mothers and infants were seen during a comprehensive interdisciplinary team evaluation clinic. Two physical therapists were involved in the study. Two therapists were used to assess the possible effect of tester differences in teaching skills and to control for tester bias because 1 tester was the author of the study. Tester 1, the author, had 11 years of experience as a physical therapist and had specialized in pediatrics for 9 years. Tester 2 had been a physical therapist for 10 years with 6 years of experience in pediatrics. Both testers had extensive experience working with infants and families of low SES. Both testers completed training using the TIMP. Rater consistency was established by comparison of tester scoring of sample videos with scores of raters with established reliability using Rasch analysis. The standard for achieving tester reliability was less than 5% misfitting items.6 In an attempt to make the tester’s teaching consistent, the testers observed each other teaching the TIMP to families before initiating the study and followed a teaching script. To determine that the outcome of the intervention was truly due to the mothers observing the TIMP performed on their infant, the lead physician for the clinic also observed each tester administer the TIMP to infants with a mother present. The physician noted the presence of similar teaching behaviors on all observations that she made and it was concluded that the teaching environment was consistent between testers. Before data collection, tester 2 was also instructed in the study procedures, guidelines, the telephone survey, and the teaching scripts for administering both the TIMP and the telephone survey.

Tester 1 contacted the mother the day of the clinic visit, discussed the purpose of the study, and obtained signed consent. Once tester 1 had received informed consent, the mothers were given the PBMS to complete. Tester 1 then identified to which group (text-only or pictorial) the mother-infant pair was assigned based on the last 2 digits of the medical record number. Tester 1 then notified tester 2 of the appropriate test format to use. Each format was used by each of the testers to allow testing of differences in teaching styles. Each tester administered and scored the infant on the TIMP using the specified test format and followed the administration guidelines. The tester instructed the mother on the infant’s current skills, expected skills in 1 month, and areas of weakness if applicable. The tester provided the mother with 3 activities to help facilitate her infant’s development and informed the mother of the importance of “tummy time,” ie, wakeful time spent in the prone position. At the end of the clinic visit, which typically lasted approximately 2 to 3 hours, tester 1 provided the mother with a second copy of the PBMS to complete before the mother left the clinic.

Approximately 3 to 5 days following the clinic visit, the mothers received a phone call from one of the testers who asked 4 questions related to the infant’s development. The follow-up phone call was used to evaluate the mother’s ability to retain information she gained from observing the therapist administer the TIMP on her infant. Tester 1 made the follow-up phone calls to the mothers whose infant had been tested by tester 2 and vice versa. The testers followed a telephone call survey script to standardize the content of the interaction with the mothers. Once the mothers completed the pretest and post-test of PBMS and the tester completed the telephone survey, the primary author scored the tests and stored the data.

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Analysis

The purpose of this study was to evaluate the effectiveness of the TIMP as an educational tool for mothers and to compare the effectiveness of the 2 formats of the TIMP (text only or pictorial). The following questions were addressed: (1) Is there improvement in the mother’s knowledge of infant motor function after the TIMP test is administered to their infant? (2) Is there a difference between the mothers’ immediate recall of infant motor function when a specific TIMP test format is used? (3) Is there a difference between the mothers’ immediate recall of infant motor function depending on who administers the TIMP? (4) Is the mother’s recall of information influenced by the interaction between the therapist and the type of format used to examine the infant? (5) Are the mothers able to retain the information taught over a short period of time? (6) Is the mother’s ability to retain information influenced by the format used? Mothers’ gains in knowledge from pretest to post-test were assessed with a t test for dependent means with a p < 0.05. A 2-way analysis of variance (ANOVA, p < 0.05) with gain score as the dependent variable was used to assess the independent effects of test format and testers on mothers’ knowledge of preliminary infant motor behavior. A second 2-way ANOVA with a p < 0.05 with total score on the follow-up phone survey as the dependent variable was used to assess the independent effects of test format and testers on the mothers’ ability to retain information about infant motor behavior. Correlation coefficients were calculated to determine whether there was a relationship between the mother’s years of education and the mother’s ability to gain knowledge in infant development.

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RESULTS

The subjects who agreed to participate included 28 mother-infant pairs, 12 mothers (43%) assigned to the TIMP pictorial format group, and 16 mothers (57%) to the text format group. Table 4 shows the sample size for each subgroup (format and tester). Eighteen mothers (64%) were tested by tester 1 and 10 (36%) by tester 2. Characteristics of the infants are presented in Tables 1 through 3. The average age of testing was 1.39 weeks adjusted age (SD = 3.3 weeks). Twenty-four infants (86%) scored greater than or equal to −0.5 SD on the TIMP or within the typical range for their adjusted age.22 Characteristics of the mothers are presented in Table 5. Mothers were, on average, 26.57 years old (range 19–34 years old; SD = 4.29 years) with 11.79 years of education (range 9–16 years) and 1.78 previous children (range 0–6 children).

TABLE 5

TABLE 5

A t test of differences between means of the mother’s pretest scores on the PBMS showed that the text group (mean = 4.6, SD = 1.5) did not significantly differ from the pictorial group (mean = 5.0, SD = 1.2). Therefore, it was assumed that mothers’ baseline knowledge of premature infant motor development was equivalent at the beginning of the study (t = 0.757, df = 26, p = 0.456). Given no group differences in baseline knowledge, the first question addressed in this study was whether the TIMP is an effective educational tool, ie, does observation of the TIMP performed on their baby, regardless of test format, increase mothers’ knowledge of infant motor development? The t test for dependent means comparing the pretest results on the PBMS with the post-test results for all mothers showed a significant improvement in their scores from a mean of 4.8 (SD = 1.3) on the pretest to a score of 6.6 (SD = 1.4) on the post-test (t = 5.525, df = 27, p < 0.0001). The average gain was 1.7 points (SD = 1.77). Mothers’ knowledge of infant motor development was improved after observation of a TIMP performed on their baby.

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Differences in Format

The next questions addressed in the statistical analysis were (1) Is there a difference between the mother’s recall of infant motor function when a specific TIMP test format (text vs pictorial) is used? (2) Is there a difference between mothers’ recall of infant motor function depending on which of 2 therapists administers the TIMP? and (3) Is the mother’s recall of information influenced by the interaction between the therapist and the type of format used to examine the infant? The results of the 2-way ANOVA are presented in Table 6. There was an average 1.73-point improvement (SD = 1.69) for mothers whose therapist used the pictorial format and an average 1.94-point improvement (SD = 2.05) using the text format. The ANOVA produced no significant effect for format or tester. When the interaction between the independent variables was tested, the result was also not statistically significant. In summary, mothers did not learn more from observing a TIMP with 1 format compared with the other, nor from observing 1 therapist compared with the other, and the mothers did not learn more with a specific format and tester combination compared with another combination of format and tester.

TABLE 6

TABLE 6

Several interesting results were found after the mother’s answers to the specific test questions were reviewed. Most striking was that only 11% (3) of the mothers were able to answer question number 3 (Appendix A, which is available at www.pedpt.com) correctly on the pretest and 25% (7) on the post-test. There were also several questions that were most likely to improve, meaning that the mothers answered incorrectly on the pretest, but answered correctly on the post-test. Question numbers 4, 6, 7, and 9 (Appendix A, which is available at www.pedpt.com) were most likely to improve (>75%). However, 29% of the mothers (8 of the 28 mothers) answered question number 5 correctly on the pretest but answered the question incorrectly on the post-test.

Following the TIMP testing, mothers were asked on the post-test PBMS to recall and list activities to perform with their infant during the day to help with their infant’s overall development or strengthen weak areas identified by the therapist on the TIMP. Twenty-two of the 28 (79%) mothers tested were able to recall activities to perform with their infant on the day the TIMP test was provided. Examples of the activities that mothers recalled after testing included activities to improve their infant’s ability to hold their head up, to strengthen their infant’s back muscles, and ways to encourage their infant’s movement such as using their own voice or an auditory toy.

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Retention of Information

The question of whether the mothers would be able to retain the information taught, so they could follow through with activities at home to help their infant’s motor development was addressed by analysis of the phone survey results: (1) Is there a difference between the mother’s ability to retain information when a specific TIMP test format is used? (2) Does the mother’s ability to retain information depend on the therapist who conducts the teaching? (3) Is the mother’s ability to retain information influenced by the interaction between the therapist and the TIMP format? Twenty-three (82%) of the 28 mothers tested were reached for a follow-up phone call. Of the mothers who were reached for the follow-up phone call survey, those mothers were able to answer an average of 1.74 (maximum score = 3, SD = 0.86) questions correctly. A 2-way ANOVA was performed to determine the effects on the number of correctly answered questions on the phone survey for the main effects of test format and tester, and the interaction between these 2 independent variables (Table 7). The ANOVA produced a significant effect for the tester (therapist) who performed the infant’s TIMP and provided the mother’s instruction (F = 9.941 df = 1, p = 0.005). When the groups were separated by tester, the mothers scored 1.4 questions (SD = 0.737) correctly when taught by tester 1 and 2.37 questions (SD = 0.744) when taught by tester 2. When the groups were separated by the format used, the mothers scored 1.7 questions (SD = 0.823) correctly in the pictorial format and 1.77 questions (SD = 0.927) correctly in the text format. The ANOVA produced no significant effect for format or for the interaction between the independent variables. Twenty-one of the 28 mothers (91%) were able to recall activities that they were asked to perform with their infant to help their infant’s development. The results show that the mothers were able to retain information taught during the therapy session over a short period of time.

TABLE 7

TABLE 7

To determine whether there was a relationship between the mother’s years of education and the mother’s ability to gain knowledge in infant development after observing a TIMP examination, 3 correlation coefficients were calculated. The results of the correlations are in Table 8. The correlation analyses showed no significant relationships between the mother’s years of schooling and the PBMS scores or gain scores.

TABLE 8

TABLE 8

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Summary

The answers to the questions posed in this study were that the mother’s knowledge of infant motor development improved significantly after observing her infant’s performance on the TIMP but neither the format nor the tester who administered the TIMP and provided education contributed significantly to the mother’s ability to improve her knowledge. Mothers were able to retain the information taught over a short period of time and the tester did influence the mother’s ability to retain the information taught but there was no statistically significant effect in the format used. Finally, parents can profit from an educational session with a therapist using the TIMP regardless of their educational level.

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DISCUSSION

The results of this study indicated that mothers were able to gain knowledge of premature infant motor development after observing their infant’s performance on the TIMP and they retained the information over a short time period. Despite statistically significant gains in knowledge following the TIMP test, average scores on the PBMS post-test were low (overall average = 6.6 correct answers). Two possible reasons that affected the mother’s ability to score on the post-test and telephone survey may have been due to the teaching environment and/or the home environment. The mothers may not have been able to retain the information taught by the therapist because the other disciplines in the clinic were also providing educational material. The home environment may not have been an ideal place for the mother to practice and utilize her new knowledge. The results found are, however, promising in that the mothers were still able to gain knowledge about infant motor development in a hectic, interdisciplinary environment. In a more relaxed, ideal environment where the mothers only meet with the therapist, it may be suggested that mothers may be able to retain more information.

Parent education is important to infant development because it encourages parent-infant relationships, helps parents learn typical developmental trends such as when infants should sit by themselves, and helps parents identify when delays may be present. One of the hypotheses of this study was that mothers would benefit from observing the infant’s performance on the TIMP. This hypothesis was supported. In this study, mothers benefited from observing their infant’s performance on the TIMP by gaining knowledge of premature infant motor development. Previous studies support the benefits of parent participation and education on infant development.17,19

Another hypothesis of the study was that the pictorial format of the TIMP would have a stronger influence on the mother’s level of understanding than the text-only format. However, in this study, the pictorial format of the TIMP did not significantly influence the mother’s ability to gain knowledge of premature infant development. Several studies have evaluated the methods used to educate individuals in the medical, developmental, and educational fields.19,21,26 Campbell et al24 found that scheduled “tummy time” increased with parent education, and the frequency increased when a pictured brochure was given. Although in other studies it was concluded that pictured formats enhance the individual’s ability to learn, similar results were not found in this study. Further research is needed on how the teaching experience could be more effective when using the pictorial format.

Another hypothesis of the study was that the tester would not influence the mother’s level of understanding. However, in this study, the tester did influence the mother’s ability to retain knowledge gained on premature development. Variations in the teaching styles may have resulted although specific teaching guidelines were outlined in the procedures. Because tester 1 was the author and created the format, tester 2 may have deviated from the procedures slightly out of practice habit and may have used additional teaching techniques to enhance the mother’s ability to retain information. One example may have been to ask the mothers to demonstrate or immediately recall the activities to perform. Smith et al27 found a positive relationship between the cognitive level of an elderly population and their ability to remember a physical therapy exercise program. Physical therapists often give specific exercise instructions, and the exercises are practiced with the physical therapist’s feedback until the patient performs them correctly. Often physical therapists ask the patients to demonstrate the exercises to ensure correct performance. Although common in practice, this was not a specific guideline that the 2 therapists in this study were asked to follow. Rastall et al28 found that patients were able to remember their physical therapy exercises better when the teaching involved the patient’s motor performance of the exercises. Learning has also been more effective when written instruction is provided to patients.20,26 In this study, it was not part of the tester’s teaching guidelines to ask the mothers to demonstrate the exercises or provide a written home exercise program. However, one or more of these methods may have been used causing the significant difference between testers in the mother’s ability to answer the questions correctly on the telephone survey. Differences is the results by tester may also have occurred in the way the questions on the telephone survey were asked although specific guidelines were given (ie, repeat the questions no more than 3 times). Or, the results may have occurred due to indefinable occurrences based on the therapist’s inherent personality characteristics, mannerisms, language, or tone of voice used which are difficult to control but may have influenced the mother’s ability to recall or retain the information taught. Another concern is that small, fragile infants may be too fatigued at the end of the assessment for the mothers to demonstrate the home exercise program. However, adding these components to a future study may improve the mother’s ability to gain knowledge of infant development as previous research supports.

Further investigation with larger sample sizes would be needed to provide a better test of the hypothesis that the pictorial format of the TIMP is more beneficial to the parent’s understanding of premature infant motor development. However, the results are promising in that the therapist’s explanation and encouragement of the mother’s participation in observing the TIMP administered on her infant does improve the mother’s understanding of premature infant motor development. During explanation of the research to the mothers and assignment to groups, the mothers asked to participate in the pictorial group and the authors continue to suspect that the pictorial format is more attractive to parents and would be found to be more effective if tested in a larger and perhaps more diverse group of mothers.

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Clinical Implications

According to the results of this study, therapists can affect the mother’s ability to learn premature infant motor development by encouraging mothers to participate and observe the TIMP being administered to their infant. Furthermore research has shown that parents have the ability to influence their infant’s motor development. Lekskulchai et al29 examined the effect of a home program on improving motor performance in a group of Thai infants born preterm. At 4 months corrected age, the infants in the intervention group scored significantly higher on the TIMP than the control group. The study by Lekskulchai et al29 compliments the results found in this study in that if the mothers are able to gain knowledge in infant motor development from observing the TIMP performed, they have the ability to use the knowledge to directly affect their infant’s motor development.

Research supports that parental report of their infant’s current skills is predictive of developmental delay30 and that parents can identify when developmental problems exist.31 The PBMS could be further developed for use as a tool to identify the parent’s current knowledge of infant motor development, to identify the educational needs of the parent, or to screen for delays in infants to identify the need for further gross motor assessment. The PBMS could also be used as an assessment to measure outcomes of the therapist’s teaching. Coaching the therapists on better methods to teach the mothers about the TIMP could improve the mother’s ability to answer the PBMS correctly, and thus gain more knowledge in infant motor development.

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Study Limitations

If this study was to be repeated several changes should be made. A larger sample size would give more power to the statistical tests and make the results easier to generalize to a larger population. Further research on the PBMS should be completed such as establishing the constructs of the survey used to measure the mother’s knowledge and improving the psychometrics of the PBMS. The questions could be rewritten at an easier reading level and revised to include more items with ecological relevance.22 Additional variability among mothers could be limited by recruiting only mothers with 1 child. Therefore, the mother’s knowledge and experience with infants could be better controlled.

The results of this study also raise another question. Would the parents have retained more information if they had been given a copy of the TIMP at the end of the session? A previous study by Campbell et al24 indicated an increased frequency of scheduled “tummy time” when a pictured brochure was given. Parents may have had a clearer understanding of their infant’s strengths and weaknesses if they had the test to reference.

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CONCLUSION

Despite limitations in this study, the results help to build the body of knowledge about the effects of parent participation in a physical therapist’s examination and the ability of the TIMP to educate mothers about infant motor development. This research also offers new questions on the effects of parent education on further development of infants and the techniques that therapists choose to use to educate their patients and clients. Having the mothers observe their infant’s performance on the TIMP has been shown to modestly improve the mother’s knowledge of infant motor development in African American mothers.

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ACKNOWLEDGMENTS

The authors thank Michelle Bulanda, PT, DPT, MS, PCS, and Mary Keehn, PT, DPT, MHPE, who provided valuable guidance on their thesis committee. They also thank Sandra Levi, PT, PhD, for providing insight into the outcomes and usefulness of their results. The authors also acknowledge the people involved in the research: Natalie Blonien, PT, NCS, Diane Davis, PT, Lysa Farrell, PT, PCS, Colleen Hicks, DPT, PCS, Swarrupa Nimmigadda, MD, and Jaideep Singh, MD. A special thanks to Catherine Kennedy, PT, PCS, for participating as a tester, as well as to the mothers and their infants who agreed to participate and enhance the field of physical therapy.

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REFERENCES

1. Farran D. Effects of intervention with disadvantaged and disabled children: a decade review. In: Miesels SJ, Shonkoff JP, eds. Handbook of Early Childhood Intervention. Cambridge, UK: Cambridge University Press; 1990:501–539.
2. Singer L, Yamashita T, Lilien L, et al. A longitudinal study of developmental outcomes of infants with bronchopulmonary dysplasia and very low birth weight. Pediatrics. 1997;100:987–993.
3. Schmidt B, Asztalos E, Roberts R, et al. Impact of bronchopulmonary dysplasia, brain injury, and severe retinopathy of the outcome of extremely low birth weight infants at 18 months. JAMA. 2003;289:1124–1129.
4. Public L No. 108.446. Individuals with Disabilities Education Act-Part C Amendments. 108th Congress; 2004.
5. American Physical Therapy Association. Guide to Physical Therapist Practice (Guide) Revised. Alexandria, VA: American Physical Therapy Association; 2003.
6. Campbell SK, Kolobe THA, Wright BD, et al. Validity of the test of infant motor performance for prediction of 6-,9-, and 12-month scores on the Alberta Infant Motor Scale. Dev Med Child Neurol. 2002;44:263–272.
7. Campbell SK. The Test of Infant Motor Performance Test User’s Manual Version 2. Chicago, IL: Infant Motor Performance Scales, LLC; 2005.
8. Campbell SK. The quest for measurement of infant motor performance. In: Refshauge K, Ada L, Ellis E, eds. Science-Based Rehabilitation: Theories into Practice. Philadelphia, PA: Butterworth Heinemann; 2005:49–65.
9. Widmayer SM, Field TM. Effects of Brazelton demonstrations for the mothers on the development of preterm infants. Pediatrics. 1981;67:711–714.
10. Brazelton TB. Neonatal Behavioral Assessment Scale. London: Spastics International Medical Publications; 1973.
11. Unanue R. The Effect of Parent Education on the Motor Performance of Premature Infants and Parent Care Giving Abilities [dissertation]. Hahnemann University; 2002.
12. Brown M, Yando R, Rainforth M. Effects of an at-home course on maternal learning, infant care and infant health. Early Child Dev Care. 2000;160:47–65.
13. MacPhee D. K.I.D. scale and K.I.D. inventory. Presented at: Personal Conference; 1997.
14. Melnek B, Alpert-Gillis L, Fischbeck Feinstein N, et al. Improving cognitive development of low birth weight premature Infants with the COPE program: a pilot study of the benefit of early NICU intervention with mothers. Res Nurs Health. 2001;24:373–389.
15. Bayley N. Bayley Scales of Infant Development. 2nd ed. San Antonio, TX: Psychological Corporation; 1993.
16. Brazelton T, Nugent K. Neonatal Behavioral Assessment Inventory in 137 Clinics in Developmental Medicine. 3rd ed. Cambridge, England: Cambridge University Press; 1995.
17. Parker SJ, Zahr L, Cole JG, et al. Outcomes after developmental intervention in the neonatal intensive care unit for mothers of preterm infants with low socioeconomic status. J Pediatr. 1992;120:780–785.
18. Bayley N. Manual for Bayley Scales of Infant Development. New York, NY: Pyschological Corporation; 1969.
19. Feldman MA, Ducharme JM, Case L. Using self instructional pictorial manuals to teach child-care skills to mothers with intellectual disabilities. Behav Modif. 1999;23:480–497.
20. Lloyd G, Cooper A, Jackson G. Information delivery: the provision of written information for patients following coronary angiography and post-discharge management. Int J Clin Pract. 1997;57:387–388.
21. Reed LA, Hoffman LG. Pictorial cues and enhancement of patient recall of instructions or information. J Am Optom Assoc. 1986;57:312–315.
22. Campbell SK, Levy P, Zawacki L, et al. Population-based standards for interpreting results on the test of infant motor performance. Pediatr Phys Ther. 2006;18:119–125.
23. Campbell S, Kolobe T, Osten E, et al. Construct validity of the test of infant motor performance. Phys Ther. 1995;75:585–592.
24. Campbell SK, Hedecker D. Validity of the test of infant motor performance for discriminating among infants with varying risk for poor motor outcome. J Pediatr. 2001;139:546–551.
25. Murney M, Campbell SK. The ecological relevance of the test of infant motor performance elicited scale items. Phys Ther. 1998;78:479–489.
26. Jennings JT, Sarbaugh BG, Payne NS. Conveying the message optimal infant positions. Phys Occup Ther Pediatr. 2005;25:3–18.
27. Smith J, Lewis J, Prichar D. Physiotherapy exercise programmes: are instructional exercise sheets effective? Physiother Theory Pract. 2005;21:93–102.
28. Rastall M, Brook B, Klarenta M, et al. An investigation into younger and older adults’ memory for physiotherapy exercises. Physiotherapy. 1999;85:122–128.
29. Lekskulchai R, Cole J. Effect of a developmental program on motor performance in infants born preterm. Aust J Physiother. 2001;47:169–176.
30. Diamond K. The role of parents’ observations and concerns in screening for development for developmental delays in young children. Top Early Child Spec Educ. 1993;13:68–81.
31. Glascoe F, Dworkin M. The role of parents in the detection of developmental and behavioral problems. Pediatrics. 1995;95:829–836.
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Appendix A

Survey Premature Baby Motor

The purpose of this survey is to measure whether a physical therapy examination can teach mothers about premature infant motor function. Motor function is the infant's ability to MOVE in response to different positions, sights, and sounds. Try your best to select the ONE best answer. Please answer ALL of the questions. If you are not sure of the answer, please choose the one you think is best.

  1. Premature babies can
    1. try and lift their head in sitting
    2. smile
    3. suck on their hand
    4. follow moving objects with their eyes
    5. all of the above
  2. Which of the following do premature babies do first?
    1. hold their head up in sitting
    2. suck on their fingers/fist with their head turned to the side
    3. suck on their fingers/fist with their head in the middle
    4. reach for objects
  3. It is most difficult for a premature baby to follow a ball with their eyes
    1. while lying on their back
    2. when held in sitting
    3. while lying on their side
  4. Is it a good idea to place premature babies on their stomach to play?
    1. yes
    2. no
  5. It is most difficult for premature babies to hold their head in the middle
    1. when they are on their back and their arms are placed on their chest
    2. when they are on their back and their arms are NOT placed on their chest
    3. when the infant is held in sitting
  6. The usual way premature babies stand when held is
    1. toes pointed and legs stiff
    2. feet flat and “bouncy knees”
    3. knees buckle and babies sit on their heels
  7. When premature babies are helped to roll from their back to their stomach
    1. they lift their head, then their body turns
    2. their body turns, then they lift their head
    3. they arch their back
  8. When premature babies are laid on their stomach and spoken to in a soft voice, they first learn to listen, then
    1. move their head across the surface toward the voice
    2. hold their head up and look for the voice
    3. roll to their back
  9. When a small blanket is held over a premature baby's eyes, they
    1. enjoy it and fall asleep
    2. try to take it off by wiggling their head out
    3. try to pull it off with their hands
  10. When premature babies are gently brought up by their arms into a sitting position from lying on their back, they
    1. first tuck their chin to their chest, then help with their arms
    2. first help with their arms, then tuck their chin to their chest
  11. Motor skills are the infant's way of moving their arms, legs, and bodies in response to different positions, sounds, or visual stimuli. Do you know what movement activities to expect of your infant in the next month?
    1. yes
    2. no

If yes, please list three activities:

Answers: 1. e; 2. b; 3. b; 4. a; 5. c; 6. b; 7. b; 8. a; 9. b; 10. b.

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Appendix B

Telephone Survey

Approximately 3 to 5 days after the infant's evaluation in the Center for Health Families, a tester will call the mother. The tester will explain the purpose and length of the call. Then, the tester will ask the mother the following questions. The mothers will be told to select one best answer. Once the survey has been completed, the tester will be available to answer any questions.

  1. Is it most difficult for a premature baby to follow a ball with their eyes
    1. while lying on their back
    2. when held in sitting
    3. while lying on their side
  2. The usual way premature babies stand when held is
    1. toes pointed and legs stiff
    2. feet flat and “bouncy knees”
    3. knees buckle and babies sit on their heels
  3. When premature babies are laid on their stomach and spoken to in a soft voice, they first learn to listen, then
    1. move their head across the surface toward the voice
    2. hold their head up and look for the voice
    3. roll to their back
  4. Are their any activities that the therapist asked you to practice with your infant at home?
    1. Yes
    2. No

If yes, can you please list the activities:

Answers: 1. b; 2. b; 3. a.

Keywords:

child development; human movement system; infant; mothers/education; motor skill; parenting education; physical therapy

© 2008 Lippincott Williams & Wilkins, Inc.