Developmental and Therapeutic Interventions in the NICU

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9781557666758: Developmental and Therapeutic Interventions in the NICU

The most comprehensive book available on neonatal intervention, this in-depth resource gives professionals the strong foundation of clinical knowledge they'll need to work with high-risk newborns. With a unique developmental and therapeutic perspective that sets it apart from other texts on the subject, the book is filled with research findings and practical guidelines clinicians will use to promote the well-being of infants in the NICU and to involve and support their families. In-service and preservice professionals will benefit from

  • an exploration of different developmental models for neonatal intervention
  • an overview of medical conditions of newborns and commonly used interventions
  • a synopsis of the functional abilities of premature infants
  • discussion of crucial elements within the NICU environment, including teamwork, equipment, and sources of support
  • detailed guidelines for positioning and feeding
  • a model for family-centered care
  • guidance on assessing behavior and development
  • suggestions for working with infants with prolonged NICU stays
  • tips on easing the transition from hospital to home
  • information on following up with high-risk infants

The overviews, learning objectives, and case stories in each chapter make this an ideal textbook for new and future clinicians, and the guidelines for everyday practice make it a reference professionals will use again and again as they work with high-risk infants and their families.

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About the Author:


Elsie R. Vergara, Sc.D., OTR, FAOTA, received a bachelor of science degree in physical and occupational therapy in 1968 and a master of public health degree in maternal and infant health in 1977 from the University of Puerto Rico. Her interest in neonatal care emerged during her clinical experiences in Puerto Rico. These experiences took place when major medical and technological advances in neonatal practice were occurring in the United States. Dr. Vergara moved to Boston to pursue a doctoral degree that would expand on the knowledge and skills in neonatal intervention that she had acquired through intensive self-study and her master's-level experiences. Dr. Vergara received training from respected neonatal care scholars such as Dr. Kevin Nugent and Dr. Heidelise Als, and in 1987 she earned a doctor of science degree from Boston University. Following the reauthorization of the Education of the Handicapped Act Amendments of 1986 (PL 99-457) as the Individuals with Disabilities Education Act Amendments of 1991 (PL 102-119), states began to develop educational resources and activities to prepare personnel to comply with the mandates of the law. Dr. Vergara obtained a 3-year grant from the state of Florida to design and establish a statewide training program to prepare neonatal and early intervention physical and occupational therapists. To accomplish this task, she created a series of self-study materials that the American Occupational Therapy Association published in 1993 as a two-volume set titled Foundations for Practice in the Neonatal Intensive Care Unit and Early Intervention: A Self-Guided Manual. In 1993, Dr. Vergara was inducted into the American Occupational Therapy Association's Roster of Fellows for her contributions to the enhancement of the profession through the development and promotion of educational programs in early intervention. Dr. Vergara's interest in infusing a family-centered, developmentally supportive perspective into the training and service delivery of neonatal personnel has challenged her to conduct similar training programs in countries such as Mexico and Honduras. She plans to establish two training centers in Mexico to provide ongoing preparation of neonatal personnel.

Rosemarie Bigsby, Sc.D., OTR, FAOTA, earned a bachelor of science degree in occupational therapy from Western Michigan University in 1974, an advanced master of science degree in occupational therapy from Boston University in 1980, and a doctor of science degree from Boston University in 1994. She holds a Board Certification in Pediatrics from the American Occupational Therapy Association and in 1993 was named a Fellow of the American Occupational Therapy Association for her contributions to the practice of occupational therapy with infants and children. Dr. Bigsby's experience as a pediatric occupational therapist spans three decades, during which she has worked in a variety of settings as a clinician, supervisor, and consultant. When she began her career, sensory integration and early intervention were emerging practice arenas. The potential for applying principles of sensory integrative theory to practice in early intervention captured her interest, prompting her to advance her education and to eventually engage in research with preterm infants and their families. In the 1980s, following her graduate studies, she became Chief Occupational Therapist at Meeting Street School (now called Meeting Street Center), a center in East Providence, Rhode Island, for school-age children with multiple disabilities. She participated on the multidisciplinary diagnostic team as well as the Parent Program for Developmental Management, one of the first early intervention programs in the country, which was founded by the late Dr. Eric Denhoff. In 1990, she began her doctoral research under the mentorship of Dr. Barry Lester, focusing on physiologic and behavioral indicators of self-regulation in preterm infants. Since that time, she has contributed to a number of grant-funded research studies as a trainer and consultant. Dr. Bigsby has practiced in the NICU at Women & Infants' Hospital since 1992 in the combined roles of therapist, educator, and researcher. She was instrumental in translating the model for psychosocial and developmental support to NICU infants and their families—first described by Dr. Elaine C. Meyer, Dr. Lester, and colleagues — from a research protocol to a clinical service that is provided by the Infant Development Center team. Dr. Bigsby has authored numerous journal articles and book chapters and coauthored the American Occupational Therapy Association guidelines for NICU practice and the Posture and Fine Motor Assessment of Infants (The Psychological Corporation, 2000). She also has served as a contributor to the Neonatal Network Neurobehavioral Scale (NNNS) (Lester & Tronick, forthcoming from Paul H. Brookes Publishing Co.). Dr. Bigsby's research focuses on motor development, behavioral cues, physiologic regulation, and feeding in early infancy. She has been invited to speak both nationally and internationally, and each year, she teaches several 2-day multidisciplinary workshops on assessment and intervention in the NICU.

Excerpt. © Reprinted by permission. All rights reserved.:

Supporting Infant Occupations in the NICU

ENHANCING INFANT OCCUPATIONAL PERFORMANCE

A newborn's ability to engage in age-appropriate learning and apprenticeship occupations depends to a large extent on a variety of underlying internal capacities, as well as on critical contextual elements of supports (see Table 1). The maturation of the body systems and developmental experiences result in the emergence of underlying capacities. The rapid growth and maturational changes in the infant's first year, especially during the first few months of life, bring about ongoing changes and adaptations in the development of these underlying capacities and, ultimately, in the child's occupational performance. Basic underlying capacities include functions suchas self-regulation of physiologic processes (e.g., breathing, body temperature, oxygen saturation), state of arousal, reflex development, muscle tone, postural and motor control, sensory processing and modulation, oral-motor control, vocal (crying, fussing) and nonvocal communication, visual and auditory skills, and perceptual and cognitive skills (see Table 1). Impairment in these underlying capacities is believed to interfere with function and occupational engagement (see Chapters 8 and 9 for more detail).

Traditional versus Occupation-Based Approaches

Traditional intervention approaches focus on the development of underlying capacities or performance components as a mechanism to improve functional performance. Working exclusively at the level of underlying capacities, however, may not adequately address the developmental needs of infants, which ultimately is to become increasingly active participants in activities valued within their cultures. Issues such as ongoing changes in contextual influences as children develop challenge the traditional component-based intervention approaches. Occupation-based contextual approaches, in contrast, focus intervention on an infants' engagement in expected occupations, his or her engagement patterns and capabilities, and internal and contextual factors that interfere with or support the infant's participation in such occupations. These approaches focus on enhancing the infant's participation, specifically in the family's expected and valued occupations within the constraints and support of the infant's environmental context.

Fostering occupational performance in NICU infants is an even greater challenge. For much of the time that infants are treated in the NICU, they are critically ill and dependent on life-sustaining technology. During this period, these infants appear to be internally focused and passive — that is, they are striving to achieve and maintain physiologic stability while conserving energy for healing and growth (see Chapters 8 and 9). Lack of physiologic stability hampers an infant's efforts to engage in occupations.

The ability to engage in tasks and activities depends in many ways on the stage of maturity of the infant's rapidly developing body systems. The therapist needs to assess the infant's level of maturity and readiness for engagement to establish an effective occupation-based intervention plan in the NICU. The neonatal therapist who functions as an occupation-based developmental specialist in the NICU helps enhance the infant's performance during each stage of illness and recovery in a variety of ways. Areas of intervention include the following: 1) assessing the infant's individual strengths and vulnerabilities; 2) recommending appropriate modifications to the care environment; and 3) providing external assistance as needed to optimize the infant's physiologic stability, behavioral organization, and consequently, his or her overall performance. Individualized infant assessment is an aspect of this model that can be accomplished by many neonatal therapists, depending on their expertise. Not all neonatal therapists, however, possess the educational and theoretical background or qualifications required to become the team "expert" on other aspects of occupation-based care — designing or modifying the infant's context and providing external support to optimize performance. Each institution should determine which team members are most qualified to provide this form of support to the infant and the family, based on the professional expertise of their team members.

Occupation-based care is best accomplished in collaboration among the various members of the infant's NICU team, including the family and medical professionals (VandenBerg, 1997). Each member of the team contributes his or her unique perspective on the infant's performance, and each plays a significant role in accommodating the care plan to the infant's needs.

Framework for Intervention

An occupation-based infant intervention framework must contemplate the intricate multidimensional or multifactorial processes involved in the development of occupations. Factors such as refinement and maturation of nervous system structures, physical relations of body parts, practice of emerging skills, refinement of specific abilities (i.e., sensorimotor, cognitive, perceptual, emotional, and social), and the environmental context are intimately interrelated and in constant interaction (Thelen, 1995). All of these factors enrich the infant's tasks and activities. Other factors, such as increased alertness and arousal, foster the infant's engagement in occupations and decrease the amount of time spent sleeping or in less active tasks (Colombo, 2001). Figure 5 depicts the major factors that influence an infant's participation in procuring, exploring, feeding, or socially interacting within a NICU setting, as well as the complex interrelation that exists among the various factors. In this model, infant capacities are central to the infant's occupational engagement but form just one of numerous factors that may affect participation and performance. As seen in Figure 5, the infant's capacities are strongly influenced by characteristics of the NICU environment such as sound, light, activity, the infant's positioning arrangement, and medical and nursing procedures.

In addition to the NICU environment, the infant's ability to engage in occupations is heavily dependent on the caregivers' availability, sensitivity, and involvement. This model further suggests that infant, environment, and caregiver factors are constantly changing; therefore, from a systems perspective, the infant's ability to participate and opportunities for participating in occupations within the NICU setting result from the ongoing interaction among the various factors. Furthermore, infant participation is embedded within the cultures of influence: the hospital culture (e.g., staff, other NICU parents, visitors), the family culture (e.g., expectations, values, beliefs), and the prevailing culture of the family's community. The extent and quality of an infant's ability to engage in such occupations are the result of interaction within the entire system.

Occupation-Based Assessment

Neonatal therapists must keep in mind the complexities of the developmental process when analyzing occupational performance in infants. A common mistake is to develop intervention plans based on speculation about the functional implications of the observed underlying factors or performance components' deficits. Although formal instruments to assess occupational performance in infants are not available, when planning intervention programs for infants, therapists are strongly urged to observe each infant's engagement patterns during routine care and other elements intimately associated with occupational performance. These elements include family values, concerns, needs, and priorities, as well as the physical and social environments of the infant. A comprehensive assessment of the infant's performance should indicate not only the status of underlying factors or the age level at which the infant is functioning but also the specific areas that limit the infant's participation and the factors that enhance participation. Lack of adequate assessment instruments for infant occupations makes it necessary to conduct an individualized, in-depth analysis of the activities that an infant is expected to perform — prior to assessing the infant directly. This analysis must identify which tasks and abilities or underlying capacities the infant must master for effective participation in the family's expected activities or occupations. Other factors that may influence participation, such as the intrinsic characteristics of the activity and contextual elements, should also be analyzed. An analysis of this type generates an informal but structured criterion-referenced assessment against which to compare the infant's performance. Table 2 presents a breakdown analysis of three sample tasks under the procurer occupation. This example is included as a template for the analysis of other infant occupations.

Beyond the neonatal period, an infant's participation in occupations becomes more active and more complex, involving other performance areas and a broader environment. Emergence of mobility promotes exploring. Procuring activities become less crucial once the infant is able to explore and actively bring the environment closer to him or her through enhanced mobility, relying somewhat less on the caregivers. Social interaction activities become more salient as cognitive, language, and social skills improve, provided that the environment reinforces the infant's emerging social behaviors. With minimal reinforcement, the infant begins to occupy his or her time with other culturally relevant activities such as performing or entertaining play. Learning occupations also begin to blossom at this age in the form of active sensorimotor learning. Educational activities are particularly important and strongly reinforced in cultures where literacy is highly valued. Working with infants, however, is further complicated by their continued, albeit decreasing, dependency on caregiver support for optimal performance. An occupational performance difficulty in an infant could stem from caregiver inability to recognize, respond to, or support the infant's performance efforts and needs, rather than from the infant's own inability to perform. The role of the caregivers — in this case, the family — becomes instrumental for eliciting the infant's optimal occupational performance and engagement.

OCCUPATIONAL ROLE OF THE FAMILY

Parental Occupations and Role Fulfillment

One of the greatest frustrations for parents whose infant is admitted to the NICU is having to relinquish their parenting roles to strangers who are considered the "experts" on their infant's care. Although there is no real critical period for the development of attachment (Bruer, 2001), the separation and fear that results from NICU admission may delay the attachment that begins to form between an infant and his or her parents shortly after birth. Even experienced parents suddenly find themselves unable to fulfill the parenting role they had been anticipating. Parents often experience fear, anxiety, depression, and decreased self-confidence after the birth of a high-risk infant, especially when the infant's life depends on frightening life-saving equipment and procedures.

Parental apprehension about handling or even touching the infant is aggravated by the limitations imposed by the wires, tubes, and alarming equipment to which the infant may be connected. The few parenting opportunities that family members may find are further hampered by the restrictive NICU environmental context. Depending on the length of hospitalization, self-efficacy — typically associated with successful role fulfillment (Trombly, 1995) — may be detained for NICU parents unless opportunities are created to foster their engagement in their preferred parenting occupations during their infant's NICU stay. Inability to fulfill basic parenting roles during this very important period for the family could lead to poor self-concept and self-esteem that, if prolonged, could potentially interfere with parental abilities beyond NICU discharge.

Typically, the birth of an infant and the infant's subsequent procurement behaviors entice parents to interact with their infant, offering parents the opportunity to practice a variety of caregiving and child-rearing occupations. Parenting a newborn generally requires adoption of the following occupations or roles:

  • Provider of the necessary resources to satisfy the infant's needs (e.g., handling, feeding, dressing, bathing, toileting)

  • Facilitator/regulator of the infant's state and social interaction (e.g., calming, consoling, cuddling, helping the infant go to sleep, arousing)

  • Environmental modulator to ensure the infant's comfort and exposure to the most optimal child-rearing environment (e.g., controlling temperature, lights, and noise; providing developmentally appropriate toys and activities)

  • Reciprocator/social interactor to promote social exchanges between the caregiver and the infant (e.g., interpreting and appropriately responding to the infant's nonverbal — and later verbal — communication; timely and contingent social play, "taking turns")

For as long as the infant remains in the NICU, these roles are largely fulfilled by nursing personnel. However, parents should be offered opportunities to begin to perform their caregiving occupations to the extent possible. A process similar to Table 2's analysis of infant occupations may be employed to analyze parental occupations, tasks, and activities that are necessary to perform a particular caregiving role, especially for NICU infants. Table 3 presents an example of this process for analyzing the parent's role as the infant's facilitator/regulator.

Three of the most important areas for which NICU infants need regulation support from their parents are analyzed: facilitating sleep, consoling/self-calming, and exploring the environment. The tasks and activities listed would enhance parental performance of the occupations required to support the infant's performance efforts. The components and capacities listed are the underlying capacities that parents need for engaging in the tasks and activities necessary to perform their caregiving role in these areas.

Parenting in the NICU

Although performing facilitator/regulator occupations becomes spontaneous and easy for most parents, parents of sick or fragile newborns may encounter considerable difficulty in fulfilling such basic tasks during their initial parenting experiences. Self-efficacy in parenting is best achieved when there is a "goodness of fit" between the parent and infant (Thomas & Chess, 1989). Goodness of fit presupposes that parental resources (e.g., physical, financial, social/emotional) are adequate to meet the needs of the infant and the parents. The greater the infant's needs (e.g., for an infant in the NICU), the more resources the parents may need to fulfill those increased needs. Parents and infants who experience a poor fit are likely more vulnerable to ineffective parental role fulfillment. Thus, a major component of neonatal intervention should be to decrease the family's vulnerability and increase their resiliency by enhancing goodness of fit between th...

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