Friday, March 1, 2013

Neurodevelopmental Treatment: Just One Piece to the Puzzle

Neurodevelopmental Treatment: Just One Piece to the Puzzle

by Geralyn Spiesz, an Occupational Therapist and a mother to a child with T21

Having a 10 year old with T21 sit in OT 3x/week and practice handwriting is not going to create change in his brain to improve ability. It seems the old adage 'practice makes perfect' is a bit flawed when applied to our children.
As an OT, I struggled with this idea because it undercut everything I had been been taught.
As a mother, I intuitively knew it to be the case…

Results from a recent study indicated that neither of the 2 treatment models [Occupational and Physical Therapy and Neurodevelopmental Treatment] that are commonly used with young children with motor impairment was effective in enhancing children’s rate of motor development or quality of movement, at least over a 1-year time period. These findings add to an increasing body of literature indicating that contemporary motor intervention procedures are not adequately meeting the hopes and vision for motor intervention. These findings also serve as a call for the field to explore alternative treatment methods for providing services. In particular, there is a need for greater involvement of parents in intervention. There is also a need for a renewed research agenda that explores issues related to the intensity of services and dynamic motor theory. Funding models need to be modified to encourage recommended and innovative motor intervention practices. 
                                                                                                                                                                                                                                                     -Mahoney 2004

The above abstract is from a study done in 2004, which looked at children with Down Syndrome (hereafter referred to as T21, short for Trisomy 21) and Cerebral Palsy over the course of one year. One group of children received traditional interventions based on milestone mastery through structured play and traditional skill remediation techniques (traditional Occupational and Physical Therapy). The other group received Neurodevelopmental Treatment (NDT).

What is Neurodevelopmental Treatment?

NDT is a hands-on, problem solving approach that continues to evolve and change as the child’s development evolves and changes. Intervention involves direct handling and guidance through specific movement experiences to optimize function by “feeding” the correct patterns directly into our children’s perceptual experience.

For example:

Our children often have trouble with coordination and fine motor skills (the ability to easily and expertly use their hands). An OT may have the child practice tying shoelaces, or handwriting, or stringing beads, etc., over and over again. Unfortunately, this simply gives the child ample opportunity to practice those skills at the level they have mastered.

An NDT therapist will recognize the relationship between low muscle tone and decreased sensation, which may be causing a variety of issues such as poor coordination and poor fine motor skills. The therapist will put a plan together which inputs pressure (propriocetion) and movement patterns directly to the brain to increase the likelihood that neurological change will occur.

The approach is guided by the client's reactions throughout every treatment session. NDT is a forward looking approach which is – finally -- a good reason to overlook all those lists of “what to expect” from physical, cognitive, and behavioral development of children with T21!

NDT is not a static set of rules, but an evolving method based on the child. NDT therapists are experts at movement patterns and ways to use their hands to elicit those patterns. Many OT and PT’s are familiar with NDT approaches and may even incorporate certain principles into their treatment sessions, however pure and comprehensive NDT treatment must be provided by an NDT certified therapist. You can usually find lists through your local OT and PT communities.

So why then, at the end of one year did the study reveal no real accomplishments of either the traditional therapeutic interventions or NDT with our children?

I believe the answer lies within the context of environmental opportunity.

Neuroplasticity: Our Brain Grows and Changes

There are so many theories that fascinate me, both as an Occupational Therapist and a mother to a child with T21. While the concept of neuroplasticity (the ability of our brain – the central nervous system [CNS] to grow and change in response to injury) is hardly new, it is usually applied to theories of stroke, head trauma and the rehabilitation of other such brain injuries that have a definitive cause. Gene over-expression created by the extra chromosome in T21 sets in motion many imbalances that results in an injury to our child’s brain -- the symptoms of which are collectively referred to as “Down Syndrome.”

In terms of neuroplasticity, it matters not whether the cause was from a car accident, traumatic birth or an extra chromosome -- the fact remains there is a functional injury to the brain. If this approach is accepted, then providing treatments and therapies to simply address observable symptoms is all for naught. Having a 10 year old with T21 sit in OT 3x/week and practice handwriting is not going to create change in his brain to improve ability. It seems the old adage “practice makes perfect” is a bit flawed when applied to our children. As an OT, I struggled with this idea because it undercut everything I had been been taught. As a mother, I intuitively knew it to be the case.

Epigenetics: Our Environment Can Cause Change

Another truly fascinating field of study is epigenetics. The guiding premise behind this field of research is that environmental factors can alter the way our genes are expressed. “Environmental” can mean anything from everyday sensory and movement experiences, to balanced metabolic environments and nutrition, to high expectations, wellness, opportunity and unconditional love.

Epigenetics + Neuroplasticity= Endless Opportunity

When we approach our child with T21 from the perspective that his CNS is capable of continual growth and change, as well as considering environmental factors (and all that entails) can alter gene expression, we find ourselves staring at endless opportunities to positively affect development.

As crucial as NDT input is, it is truly just a fraction of the story because guided movement patterns and experiences are only as good as the opportunity the child has to use them in his everyday life. If the NDT therapist spent the morning teaching your child to log roll, going home and putting the child in a swing or a play-pen will do nothing to reinforce what his brain has just experienced.

The Floor: a Place to Learn

 Clear the furniture out of the center of the room, put down a few mats, and put the child on the ground (If there are no medical contraindications, the child should be on their tummy!) -- and leave him there. Better yet, get on the floor with him. Explain to his siblings that because their brother is getting so strong, he needs to be challenged (quite a stark departure in perception from focusing on the things he can’t do!). Create rolling games the siblings can play with him. If you want to read to him, get on the floor with him. If the babysitter is coming over, tell her to play games with him on the floor. If he is in daycare, speak with the teachers about your desire for continual floor time with opportunities to roll. Providing continual environments, frequent opportunities and heightened expectations, you are creating a powerful intervention. The glue that binds the approaches together boils down to perception. In this scenario, days fly by filled with games, laughter, bonding and creativity.

Therapy: a "Way of Life" rather than a "To-Do" List

This perspective is a very different reality from the “to-do” list mentality of making sure you getting your child on the floor X times a day and making him roll X number of rolls. The perception that this child has “special needs,” and therefore the joy is sucked out of everything, because he has to spend his time doing “therapy.” If your child sees his siblings playing games and having fun while he must get on the floor and pointlessly roll for X number of times, it creates a perceptual shift in him as well -- and not for the better.
If the floor is where your child knows his toys, games, reading time, “roughhousing,” etc. takes place, then you are affecting his opportunity to cement the skills, initiation of the skills, environmental challenge to use the skills, his perception of himself as a creator of his own destiny (no more initiation of activity goals when he’s older, he will self direct in any environment!), his visual perceptual skills, his sensory integration skills, his cognitive skills and his experience of your expectations. He will have a safe, consistent, reliable and frequent place to get the idea and time to process and use the skills taught by the NDT therapist.

NDT is a critical input to the brain -- it is showing the brain what a proper movement, posture, etc, should feel like. Neuroplasticity makes permanent change possible, especially in the very young. Epigenetics tells us to concern ourselves with environments. Nutrition, supplementation, opportunity, wellness, joy, laughter, unconditional love, are just some of the environments we can control.

Parents very often are looked at as the “therapy carryover,” that basically therapy is only effective if the parents can complete the “to-do list.” This is a joy-sucking process -- one which will undermine everything you are trying to accomplish.

The key to blending these approaches and getting real results boils down to parents. Not how much money we have, or how diligently we carryover the to-do list, but in the very reason we had children to begin with.

To love, teach, have fun with, and enjoy all that childhood has to offer.
All of these things change our children’s brain. All of these things change our perspective.
All of these things will dramatically impact his future.

Recommended Reading

Early Motor Intervention, The Need for New Treatment Paradigms

Neurodevelopmental Treatment
Doman, G. (1994). What to do About Your Brain Injured Child; or Your Brain-Damaged, Mentally Retarded, Mentally Deficient, Cerebral-palsied, Spastic, Flaccid, Rigid, Epileptic, Autistic, Athetoid, Hyperactive, Down’s Child. Garden City Park, NY. Avery Publishing Group.

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