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IES Grant

Title: Efficacy of the START-Play Program for Infants with Neuromotor Disorders
Center: NCSER Year: 2015
Principal Investigator: Harbourne, Regina Awardee: Duquesne University
Program: Early Intervention and Early Learning      [Program Details]
Award Period: 4 years (7/1/2015-6/30/2019) Award Amount: $3,430,109
Type: Efficacy and Replication Award Number: R324A150103

Co-Principal Investigator: James C. (Cole) Galloway (University of Delaware)

Long-Term Follow-Up Award: 3 Years (FY 2020—FY 2022), $929,509

Purpose: The purpose of this project is to evaluate the efficacy of Sitting Together And Reaching To Play (START-Play), an intervention designed to target sitting, reaching, and motor-based problem solving to improve development and readiness to learn in infants with motor delays or dysfunction. There is limited research examining the efficacy of early physical intervention on infants with neuromotor dysfunction. In addition, most early motor interventions have not been directly linked to learning, despite the research demonstrating an association between motor activity and cognitive skills. START-Play specifically targets motor skills that lead to greater physical exploration, which has been associated with improved problem solving and global development. A randomized controlled trial of START-Play was conducted across four states to investigate the impact of the intervention on changes over time in sitting and reaching, subsequent changes in global cognitive development, and the mediating influences of motor skill changes and problem solving.

Project Activities: The research team conducted a randomized controlled trial to evaluate the impact of START-Play on motor development, motor problem solving, global development including cognitive problem solving of infants with neuromotor delay and dysfunction. Infants experienced either the intervention or services as usual for 3 months, with initial follow-up assessments at three time points up until 9 months post intervention. They are using linear mixed modeling to examine group differences in outcomes, as well potential moderators. Further, growth modeling will be used to examine the hypothesis that the longer-term impacts of the intervention will occur through mediated pathways. More specifically, the researchers will determine whether the intervention leads to improved sitting and reaching, which leads to improved motor-based problem solving, which leads to improved global development and problem solving.

To examine longer-term impacts of START-Play, the research team received $929,509 in additional funding to collect follow-up data 24 and 36 months after the baseline assessment.

Products: The products of this project will include evidence of the efficacy of START-Play on motor skill development and global cognitive development, peer-reviewed publications, and presentations.

Structured Abstract

Setting: The research is taking place in the homes of infants and their families in Pennsylvania, Delaware, Washington, and Virginia.

Sample: There were 134 infants (age 7 to 16 months) with neuromotor disorders, as well as their families and interventionists, randomized into treatment and control groups at the start of this study. Infants had gross motor delays but were able to sit propped up for at least 3 seconds when they were recruited for participation.

Intervention: Sitting Together And Reaching To Play (START-Play) is an intervention for infants with motor dysfunction or delay in which physical therapists visit the child's home to target work on siting, reaching, and problem solving. The therapist visits the home twice weekly for 3 months. During these visits, therapists and families work together to provide intensive, individualized, daily activities to advance reaching and sitting through small increments of challenge and support for these skills, which then become the building blocks for motor-based problem solving. More specifically, the intervention focuses on self-initiated, goal-directed movements to build orientation and attention to objects, while learning basic relationships of cause and effect. Infants and families in the intervention group received this intervention in addition to their usual early intervention services.

Research Design and Methods: This study used a randomized controlled trial in which infants and their families were randomly assigned to the intervention group (START-Play in addition to usual services) or control group (usual early intervention services), stratified by severity of neuromotor disorder. There were six measurement sessions during the 12-week intervention period, followed by assessments during 1-, 3-, and 9-month follow-up visits. The study aims to determine the efficacy of the intervention on sitting and reaching (proximal outcomes) and motor-based problem-solving skills (longer-term proximal outcome), which are hypothesized to serve as mediators to the more distal outcomes of global cognitive development and readiness to learn. The investigators are also exploring fidelity of implementation to identify conditions that support fidelity and outcomes, as well as identifying other moderating factors related to the child (severity of disorder, health, age, cognitive skill at entry), family (socioeconomic status, home environment), or services (fidelity of implementation, other services provided to child) to explore change over time. With additional funding, the research team will examine longer-term impacts of START-Play by collecting follow-up data at 24 and 36 months post baseline.

Control Condition: Infants and their families in the control condition continued to receive their regular Part C early intervention services.

Key Measures: Primary outcome measures in the study include the Gross Motor Function Measure and an observational measure of toy contacts for sitting and reaching, and an adapted version of the Individual and Growth Development Indicators (Early Problem Solving Indicator) and Bayley Scales of Infant and Toddler Development —Third Edition for problem solving and global development. Secondary measures include additional measures of postural control and reaching, child and family characteristics, and fidelity of implementation (logs and checklist). At the longer-term follow up, additional outcomes will be measured with the Dimensions of Mastery Questionnaire (caregiver report of characteristics associated with future academic success such as persistence), Minnesota Executive Function Scale, and Gross Motor Function Measure.

Data Analytic Strategy: The investigators are using linear mixed modeling (LMM) to determine the efficacy of the intervention on child outcomes. Parallel process growth modeling within a structural equation modeling framework will be used to examine whether improvements in sitting and reaching are mediators leading to improvements in problem solving, which is then a mediator leading to long-term global cognitive development. LMM will also be used to examine moderating variables, as well as secondary motor outcomes. For the longer-term outcomes, additional analyses will include analysis of covariance.

Project website:

Project Video:


Journal article, monograph, or newsletter

Ryalls, B. O., Harbourne, R., Kelly-Vance, L., Wickstrom, J., Stergiou, N., and Kyvelidou, A. (2016). A Perceptual Motor Intervention Improves Play Behavior in Children with Moderate to Severe Cerebral Palsy. Frontiers in Psychology, 7. doi:10.3389/fpsyg.2016.00643 Full text