Behaviour Intervention - Neurodevelopment approach

Neurodevelopmental Therapy Approach

The Neurodevelopmental Therapy Approach (NDT) which is one of the most common intervention methods utilized in the intervention of children with developmental dysfunction was first used in the therapy of children with cerebral palsy. Later, it was used in the intervention of many developmental disabilities. The NDT approach focuses on the normalization of hyper or hypotonic muscles, the specific handling intervention of equilibrium reactions and the child's movement and its facilitation. NDT is a popular therapy method within the intervention approaches of infants and children with neuromotor dysfunction (Bobath 1980, Harris 1981).

NDT has included three basic components related to neuromotor control:

  1. Postural tonus
  2. Reflexes and reactions
  3. Movement patterns

One of the primary purposes of NDT is the facilitation of normal muscle tone in order to maintain normal postural and movement patterns. For this purpose, researchers have focused on a complex facilitation-inhibition process for many years. The Bobaths recognized that inhibition is a major factor in the control of movement and posture. It is considered to be important in the development of selective and graded movement for function. Many studies on the effects of NDT were conducted by Bobaths and other researchers, and the outcomes were satisfactory (Bobath and Bobath 1967, Bobath 1980, Bobath 1990, DeGangi et al. 1983, Ottenbacher et al.1986, Lilly and Powell 1990, Mayston 1992).

In the Bobath method, the child's functional skills are observed, and analyzed. The intervention is based on this detailed analysis, and it is customized. With functional activity education, the effects of the intervention are increased. In this approach, normal postural reactions, or problems in the relation between the central postural control mechanism and coordination need to be defined first. For automatic and voluntary activities, normal postural tonus, normal reciprocal interaction of the muscles and automatic movement patterns are priorities. All upper motor neuron lesions can be described as a disturbance to this mechanism, resulting in abnormal postural tone (spasticity, hypotonia, fluctuating tone), disordered reciprocal interaction of muscles (overfixation, lack of grading), and a disturbed automatic background of activity on which skills can be performed (Mayston 1992).

The Bobath method was used with more dynamic and functional approaches in later years. Automatic righting, equilibrium and protective reactions which were thought to be the basis of functional and voluntary movements began to focus on the facilitation. In order to enable the child to control equilibrium reactions and movements by himself, technical approaches that were applied manually were utilized less. In such an approach, because the child's reactions are corrected by the therapist's techniques, more interaction takes place between the therapist and child with a disability (Mayo 1991).

Combined Interventions

In studies conducted in the child with an intellectual disability, researchers facilitated normal mental and motor development by utilizing different stimulation techniques together. In children with developmental problems, approaches such as sensory integration intervention, perceptual-motor intervention, neurodevelopmental therapy, vestibular stimulation, play therapy, language-cognitive approaches are more effective when used individually or consecutively as may be required (Bobath and Bobath 1967, Ayres 1972a, Ayres 1979, Bobath 1980, Bumin and Kayihan 2001, Uyanik et al. 2003a, Jobling 2006).

The purpose of the NDT approach used together with play therapy is to develop individual cognitive and perceptive skills, to enable appropriate activity experiences that provide stimulus to normal movement patterns and to motivate the child by supporting normal developmental needs within the program. For this purpose, by performing activity analysis first, the therapist determines the important sections of the activity according to the child's needs and NDT targets. In this analysis, the child's motor, cognitive, perceptual and psychosocial needs and activity components are assessed. In addition, the specific NDT instrument is determined according to the child's needs. Subsequently, by giving play activities suitable for NDT techniques, the therapist enables the child's active participation in daily life activities (Anderson et al. 1987).

In enabling the child to acquire skills, the interaction of human and non-human environmental factors is significant. Therefore, the intervention should be directed not only by taking the child into the program but also by environmental adaptations that increase the child's functioning and by activities such as play activities that are multipurposeful. Thus, the child actively participates in the intervention process, skills and roles are practiced and the child becomes able to discover and integrate sensory information received from the environment by forming meaningful relations with people and objects (Lindquist et al. 1982a, 1982b). From this concept, Child-Centered intervention and Structural-Developmental intervention terms were defined to be used in the intervention of infants and young children with attention and emotional problems. In Child-Centered intervention, the child starts the play activities, and the therapist is the observer and facilitator. As in approaches applied in Snoezelen or multimodal sensory rooms, the environment is organized by arranging the available toys and materials, and a safe environment is created in which sensory-motor development can be increased without imposing prohibitions, or creating a feeling of failure (Uyanik et al. 2009). In the Structural-Developmental intervention approach, the child is taught how to gain developmental skills, and how to develop motor functions needed for sensory integration and skill performance. While this intervention is being applied, NDT or perceptualmotor training techniques can be used together to facilitate the child's performance (DeGangi et al. 1993).

General principles of combined programs applied on child with an intellectual disability as follows:

  1. By taking the children's intelligence into consideration, activities that are easy to learn, and comprised of the easiest possible movement components are chosen.
  2. The order of normal development is followed in the program. Following the assessment of reflex development, the appropriate activities are chosen after determining the level of weakness of integration between the child's response at one level below and top level adaptation behavior. The activities are adapted to supine-prone position, quadruped, sitting, and standing positions within the order of development.
  3. By having each child work alone in the same room, confuse effects which may be caused by other people or the room arrangement are avoided.
  4. By utilizing each equipment appropriately during programs, the amount of stimulation is adjusted to the tolerance level of the child. By equipping the therapy room with equipments that provide different sensory stimulations, play surroundings alternatives are created within the environment, thus enabling attentiveness and motivation.
  5. In the improvement of sensory-perception-motor responses, the development of proprioceptive feedback is beneficial. Motor responses of the child are aimed to be increased by using methods such as positioning and movement activities, and applying resistance, and by utilizing touch, and equilibrium stimuli. By increasing visual stimuli besides touch and proprioceptive equilibrium stimuli, postural and motor adaptation is aimed to be achieved.
  6. The program is carried out step-by-step, from easy to difficult and only progressing once the skill in the previous step has been accomplished (Gilfoyle and Graddy 1971).

DeGangi et al. 1993 stated that the following are the issues to be considered while applying the sensory-motor approach in a combined intervention of child-centered activity and structural-developmental intervention respectively:

  • Behaviors and searching for the sensory stimulation that is needed for the self-organization of attention and motor movements
  • Forming the idea of motor movement in the general concept of play, and developing the plan
  • Organizing motor movement patterns according to activity requirements
  • Increasing tactile-proprioceptive and vestibular sensory inputs which are formed in daily activities
  • Practicing postural control and balance
  • Putting bilateral integration components in order and teaching of their patterns
  • Teaching of motor planning components with the external direction of the therapist
  • Enabling the acceptance of sensory stimulation under the direction of the therapist and enabling this to be used
  • Observing and controlling behavioral responses to sensory inputs

The following are the issues to be considered while applying the neurodevelopmental therapy approach in a combined intervention of child-centered activity and structural-developmental intervention respectively:

  1. Creating motivation for movement and starting the movement
  2. Self-generation of the planned activities
  3. Detailed planning of body movements in space
  4. Practicing motor movements in play schemas
  5. Putting motor movements in order, timing, and planning
  6. Satisfaction in motor activities
  7. Developing posture and movement components
  8. Practicing real-skill performance
  9. Eye-hand coordination
  10. Equilibrium, strength, and postural adaptation, and stability

The following are the issues to be considered while applying the functional approach (Activities of Daily Living-ADL) in a combined intervention of child-centered activity and structural-developmental intervention respectively:

  1. Developing a feeling of interest in performing daily activities and motivation
  2. Developing the effort of self-expression by using various activities such as drawing
  3. Experiencing learned functions by using daily life devices
  4. Developing visual-spatial skills within the environmental setting
  5. Developing creative self-expression through play, artistic activity, movement and other activities
  6. Developing more complex play levels
  7. Practicing self-care skills
  8. Developing perceptual and visual-motor functions which are necessary for learning
  9. Transferring skills learned in therapy to the school and home environment (DeGangi et al. 1993).

Family Education

To help develop the potential of the child, education and rehabilitation programs should be initiated in the neonatal period. The aim is to establish a close relationship between the infant and the family and start developing independence in occupational performance areas in developmental milestones. It is important that the family is aware of the help they can get from the professionals and the areas of learning in which the infant needs stimulation. Ayres stated that there are five important things that parents can do:

  1. recognize the problem so that they will know what their child needs
  2. help their child to feel good about himself
  3. control his environment
  4. help him learn how to play, and
  5. seek professional help (Ayres 2005)

Sensory integration, vestibular stimulation, neurodevelopmental therapy approaches etc. (combined sensory-motor and language-cognitive approaches) together with educational, behavioral and pharmacological interventions on a lifespan focus for the child may be beneficial. All children with Down syndrome do not progress at the same rate and progress is slow. Other factors such as health needs often limit the time available in the typical developmental period but with ongoing assistance motor milestone can be attained and supported (Uyanik et al. 2003a, Jobling & Virji-Babul, 2004).

Family education within early intervention programs for infants should give importance to the prone position and the variety of movement, and should consist of occupational therapy / physiotherapy programs toward the development of postural reactions, proprioceptive and vestibular stimulation, the perception of the sense of touch and body awareness, ocular control and the development of visual-motor coordination. As the child grows up, educating the family on sociocultural and spiritual components, besides mental and physical components of occupational performance, will increase the success of social integration of the child with an intellectual disability.

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