Dynamic Systems Theory: Reflex Integration

• The role of physical therapy in the NICU includes screening for direct services; referral for consultation with other healthcare professionals; and referral for development services post-discharge through early intervention (EI) or outpatient therapy.
• Physical therapists design and implement interventions adapted to meet the infant’s physiologic, motor, neurologic, and developmental needs.
• The physical therapist collaborates with other healthcare team members to meet the needs of the infant and support family members.
• Incorporating the family into the delivery of care supports the infant's developmental outcomes.

Early Intervention (EI)

• EI aims to prevent delays or promote age-appropriate developmental skills.
• Early intervention is federally mandated under IDEA Part C and is locally funded.
• EI philosophy centers on family, teaching families strategies to help with daily routines and promote development in a natural environment.
• Serves children from birth to 3 years old.
• Goals are based on family and developmental needs.
• Takes place in the child's natural environment.
• Program duration includes a 6-month and 12-month program review of the Individualized Family Service Plan (IFSP).
• Review progress in all areas of development with service providers, parents, the service coordinator, and a county EI official.
• A services will discontinue when a child reaches their third birthday and "ages out".
• CPSE (Committee on Preschool Special Education) referral for preschool services are an option.

IDEA Part C

• Stipulates that early intervention services are designed to meet the developmental needs of an infant or toddler with a developmental delay or disability, or diagnosed physical/mental condition with a high probability of resulting in developmental delay.
• Eligibility for early intervention varies because each state has its own definition of developmental delay.
• Outlines philosophies of individualization, collaboration with families, coordination, and provision in natural environments.

Qualifying for EI Services

• Anyone can initiate a referral for EI services.
• A child must qualify for services with standardized testing OR have a qualifying diagnosis.
• If a child is eligible, an Individualized Family Service Plan (IFSP) is developed.
• Developmental delay must be present in one or more domains: physical, cognitive, communication, social-emotional, and adaptive.
• Severe delay is defined as a 33% delay, or more than 2 standard deviations (SD) below the mean in at least one domain.
• Moderate delay is defined as a 25% delay, or more than 1.5 SD below the mean in two or more domains.

Developmental Domains:

• Physical: Gross and fine motor skills, growth, and overall health.
• Cognitive: Thinking and learning.
• Communication: Expressive and receptive abilities.
• Socioeconomic: Interacting with others.
• Adaptive: Self-care/self-help skills like feeding and dressing.

Services offered in EI include:

• Family education and counseling, home visits, and parent support groups.
• Special Education Instruction, Speech Pathology and Audiology.
• Occupational Therapy, Physical Therapy, and Psychological Services.
• Service coordination, Nursing services, and Nutrition services.
• Social work services, Vision services, and Assistive technology devices and services.

Family-Centered Interventions:

• Caregivers know their children best and families are unique with different strengths and needs.
• Chronic conditions influence all aspects of family function.
• Intervention is a collaboration between therapist and family.
• Therapists can build on identified family strengths to meet goals.
• Therapists assess family routines to support incorporating therapeutic strategies into daily activities.
• Therapist provide families with clear options to empower informed decision-making.

Preschool Services

• Designed to develop age-appropriate developmental skills.
• Are federally mandated under IDEA Part B, and county funded, managed by the school district.
• Impairments must affect the child's performance or participation in educational programs
• Serves children aged 3–5 years.
• Must be educationally relevant.
• Services take place in the child's natural environment or preschool.
• Services are provided during the school year.
• At least 1 annual review/re-evaluation meeting occurs per school year to review progress in all areas.
• With continued qualification, a new IEP with updated goals.
• When the child is eligible for kindergarten (5 years old), services are discontinued or a CSE referral is made for school-based services.

IDEA Part B

• All children 3 to 21 years of age are entitled to a free appropriate public education (FAPE) that emphasizes special education and related services designed to meet their unique needs and prepares them for further education, employment, and independent living.
• Preschool (CPSE) serves those 3-5 years of age.
• School-based (CSE) serves those 5-21 years of age.
• Special Education includes individually designed instruction to meet the specific needs of a child with a disability.
• Related services include PT, OT, speech & language, audiology, assistive technology, and music therapy.

Free Appropriate Public Education (FAPE):

• Special Education services are provided at no additional cost to families.
• A child with a disability is entitled to an appropriate education based on individual needs.
• Children with disabilities, regardless of the severity, are entitled to be educated in the public school system.
• A child will receive the education outlined on the IEP to prepare for further education, employment, or independent living.

Continuum of Educational Placements

• Least Restrictive Environment: A regular classroom with a general education teacher.
• Regular Classroom with Accommodation/Modifications: Co-taught, co-lab, instructional aide, behavioral aide, push-in related services, and/or assistive technology; students with disabilities and non-disabled peers are educated together.
• Regular Classroom with Pull-out Services: Specialized academic instruction, intervention, or related services like speech, OT, PT, and ABA; students with disabilities spend most of their day with non-disabled peers.
• Separate Classroom (all students have IEPs): Can be called SAI, Mild-Mod, Mod-Severe, SDC, Life Skills, Functional Skills; students with disabilities spend little or no learning time with non-disabled peers.
• Separate School (all students have disabilities): A non-public school, SELPA regional program, or county program with no non-disabled peers available.
• Home education options: Independent study, home hospital, or homeschool charter with no peers available.
• Most Restrictive Environments: Residential or institutional care, hospital, or incarceration.
• Goal: Inclusive education for all students.

Qualifying for Preschool Services:

• A child must qualify for services based on standardized testing.
• If eligible, an Individualized Education Plan (IEP) is developed.
• Developmental delay in 1 or more developmental domains: physical, cognitive, communication, social-emotional, and adaptive.
• Severe Delay: 33% delay, more than 2 SD below the mean in at least one domain.
• Moderate Delay: 25% delay, more than 1.5 SD below the mean in two or more domains.

School-Based Services

• The purpose is to develop age-appropriate developmental skills.
• Policy is federally mandated under IDEA Part B and funded by the school district.
• Child-centered care, impairments must affect performance or participation in educational programs.
• Serves children 5-21 years old.
• Goals are functional and educational for the student.
• Goals should align with an area identified in the needs identified in the IEP.
• Goals should be written for the entire school year.
• Services take place in the child's school.
• Services are provided during the school year.
• At least 1 annual review/re-eval meeting occurs per school year.
• Review progress in all areas with caregiver(s), regular education teacher, special education teacher, school-district representative/CSE chairperson and other individuals with special expertise regarding the child, including related service personnel.
• With continued qualification, a new IEP with updated goals is created.
• Post-secondary transition planning starts no later than age 16.

Outpatient Services

• Can be accessed at any point along the continuum of services, in addition to school-based services, or for an acute need, episodic care, or specific goal or equipment needs.
• Goals cannot duplicate school-based goals.
• Referral is initiated by a healthcare team or through direct access.
• The need for physical therapy is determined through evaluation based on clinical judgement and objective testing.
• Therapy may address impairments, movement quality, functional limitations, and participation restrictions.
• The caregiver is ultimately responsible for payment; health insurance may assist.

The Rehabilitation Act of 1973-Section 504

• Ensures equity to access public education and services by removing barriers.
• Is an anti-discrimination statute that mandates agencies receiving federal funding (i.e., schools) treat individuals with disabilities fairly.
• A disability is defined as a physical or mental impairment that substantially limits one or more life activities
• FAPE guides the provision of reasonable accommodations and related services in school settings for students that do not need special education services.

Reasonable Accommodation Examples:

• Use of a scribe, quiet location, or an extra set of textbooks at home.
• Provide a peer tutor/helper.
• Use of an elevator vs. stairs, walking in halls with a classmate, verbal testing, adjusting the child's seating/location, or extra time to transition between classes.
• Walking in halls with a classmate or using the bathroom in the nurse’s office

Legislative Acts:

• Section 504 of the Rehabilitation Act (1973): Required recipients of federal funding to provide equal opportunities (services, supports, and accommodations) to individuals with disabilities.
• Education for All Handicapped Children Act (EHA) (1975): Origin of IDEA that intended to support state/localities in protecting children (age 5-21) with disabilities and their families.
• Americans with Disabilities Act (ADA) (1990): Extends civil rights protection to individuals with disabilities.
• Individuals with Disabilities Education Improvement Act (IDEA) (1991): Reauthorized early intervention.
• IDEA Amendment (1997): School districts must prepare an individualized education plan (IEP) for all eligible children.
• IDEA Amendment (2004): Education includes preparation for employment and independent living and includes transition planning and assistive technology.

Purpose of EI, Preschool, School-Based, and Outpatient Services:

• EI: Assist child/family to achieve family-focused outcomes and promote access to and participation in functional daily activities.
• Preschool: Develop age-appropriate skills, assist a student to achieve educational goals, and promote access to the academic curriculum and school environment.
• School-based: Similar to preschool, focuses on developing age-appropriate skills, assisting students in achieving educational goals, and promoting access to academic and school environments; addresses post-secondary transition goals.
• Outpatient: Assist in achieving functional intervention goals to enhance performance, address the medical continuum of needs (including impairments, functional limitations, and participation restriction), and improve access to the home or community.

Legislation governing EI, Preschool, School-Based, and Outpatient Services

• EI: IDEA C.
• Preschool and School-based: IDEA B-Rehabilitation Act of 1973 Section 504.
• Outpatient: Varies/Not Applicable (N/A)
• Eligible Age: EI (birth- 3 years old), Preschool (3-5 years old), School-based (5-21 years old), and Outpatient (Child with a medical dx and/or documented neuromotor, developmental, orthopedic, or sensorimotor impairments or functional limitations)

Qualifications for EI, Preschool, School-Based, and Outpatient Services:

• EI and Preschool: Standard testing OR qualifying dx and developmental delay in 1 or more domains.
• School-based: Professional judgement w/ support from standardized test, functional outcome measures, teacher report observations.
• Outpatient: Child with a medical diagnosis and/or documented neuromotor, developmental, orthopedic, or sensorimotor impairments or functional limitations PT evaluation includes hx, examination and use of appropriate tests and measures and observations within the clinic, home, or community setting

Duration and Documentation for EI, Preschool, School-Based, and Outpatient Services:

• EI: 12 months spanning months to years within the first three years of life with IFSP documentation
• Preschool: During the school year with an IEP and periodic Reviews
• School-Based: During the school year, using IEP documentation.
• Outpatient: Services can vary from a single visit to weeks, months, or even years depending on needs with SOAP note documentation.

Goals and Locations for EI, Preschool, School-Based, and Outpatient Services:

• EI: Based on family/developmental needs and take place in the child's natural environments
• Preschool: Educationally relevant and occur in a natural environment or preschool setting
• School-Based Functional and educational goals and occur in the school; the least restrictive environment
• Outpatient: Based on evaluation results in a clinic, hospital, home, community, and other settings

Theories for Neural-Maturationist, Cognitive, and Dynamic Systems:

• Neural-Maturationist Theory: Development occurs because of CNS maturation thus Primitive reflexes are the building blocks of development
• Cognitive Theory: Recognizes that Cognitive Growth and Environmental Opportunities influence Development and require experience and practice
• Dynamic Systems Theory: Denies that a single factor drives motor development, rather it is the interaction of factors including musculoskeletal, environmental, social, and psychological so Development is nonlinear

General Trends

• Reflexive to Voluntary
• Gross to Fine
• Mass to Specific
• Cephalic to Caudal
• Proximal to Distal

Primitive Reflexes

• Are involuntary responses to a stimulus.
• Each serves a different purpose (i.e., assist with birth, survival, development).
• Develop at a certain age (most present at birth)
• Are expected to integrate at a certain age (they are no longer seen).
• Do not truly disappear but are inhibited by higher levels of control.

Palmar Grasp Reflex

• Is present from birth to 4 months
• Pressure in palm on ulnar side will create a finger flexion to grip object which helps with development and survival as it lets the baby hang on to its mom

Positive Support Reflex

• Is present from birth to 2 months
• Is present from birth to 2 months; if weight is placed on balls of feet in upright position this will create stiffen legs and trunk into extension.
• Is important for development and birth.

Stepping Reflex

• Present from birth to 2 months
• In supported standing position with soles of feet on a firm surface the infant will move legs in a stepping motion
• Important for Development

Glant Reflex

• Present from birth to 2months;
• If tactile stimulus is provided lateral to spine this creates lateral spine flexion toward side of stimulus
• Aids birth & developmental progression

Sucking Reflex

• Present from birth to 3 months
• Is tactile stimulation to roof of mouth as the infant sucks on object for survival=>feeding
• Helps with rootings

Rooting Reflex

• Present from birth- 3 months
• Tactile stimulation to infant's cheek turns the head to same side with mouth open
• Survival requires feeding

Moro reflex

• Present from birth to 5 months
• Head drops into extension quickly which creates Arms abduct with fingers open-then cross trunk into adduction; & cry
• For survival and grabbing onto mom

Asymmetrical Tonic Neck Reflex (ATNR)

• Present from birth- 6 months
• As the Head turns to one side the Arm and leg on face side extend/arm & leg on skull side flex/ spine curves (convexity toward face side) and aids in development

Tonic Labyrinthine Reflex (TLR)

• Present from birth- 6months - When Child place in supine & prone position as the Supine causes trunk and extremity extension & prone causes flexion aids development

Plantar Grasp

• Present from birth to 9 months
• Pressure to base of toes creates Toe flexion & the development

Symmetrical Tonic Reflex (STNR)

Present from 6-12 months

• When the Childs places in quadruped & neck extends causeUE extension & LE flexion & Neck flexion causes UE flexion & LE extension
• Supports development

Integrated, Persistent, Absent and Obligatory Reflex Terms Defined

• Integrated Reflex: Reflex was present previously & is no longer seen whereas a Persistent Reflex is present past the time when integration is expected
• An Absent Reflex is one that is not & never was present whereas obligatory Reflex is always present and a child is stuck in a position

Postural Control vs Primitive Reflexes

• Postural Reactions: Automatic reactions that keep The body in an upright position against gravity. It is for Foundations for voluntary movement that allows an individual to respond and adapt to the changing environment since they are Responsive to specific task demands and Present for life unless are in a newrologic injury the postural Reactions can
• Primitive Reflexes: Are typically Stereotypical responses to sensory stimuli to a developing system that must Integrate as the CNS matures an as the motor, sensory and cognitive systems develop so their execution are Not stereotypical based on task demand & environment and Can be interrupted by volitional movement

Types of Reactions Defined

• Automatic reactions that maintain the body in an upright position against gravity

Types of Riighting, Equilibrium and Protective Reactions Defined

• Righting Reactions: Positions the head in space thanks to the co-contraction of neck muscles which develops a stable, midline head position in ALL planes where the Visual and vestibular systems work together to adjust the body when the center of gravity is shifted which allows the head in midline and allows the child to view the world accurately, aligns the eyes with the horizon and the head with the trunk, control of the head and the ability to see the world is vital to gaze stability and orientation to the environment
• Equilibrium Reactions: Emerges as a reaction at 5 mos and remains for life in order To stay upright against gravity where equilibrium elongation is used to shift to stabilize the WB side and shortening on the non-weight bearing side to bring the center of mass within the base of support so a person can to restore stability or "right" self during a gradual/controlled displacement of the center of mass like recognizes change in body position and responds with an appropriate weight shift by elongation on the weight-bearing side of the body in any position
• Protective Reactions: Begin to emerge at 6 mos and remains for lifr in order to create Reactive postural which allows responses to prevent injury to the head

Specific Reactions Emergence Timeline

• Optical/Vertical Head Righting Reactions: Emerges at 2 months and persists for life
• Horizontal Head Righting Reaction: Landau develops at 3 months and is under volitional control by 18 months and is tested whil being held vertically
• Rotational Head Righting Reaction: Emerges at 4 months and under volitional control by 24 months
• Elongation on WB side- Prone: 5mos, Supine: 7 mos, Sitting: 7 mos, Quadruped: 9 mos, Standing: 12 mos
• Forward Protective Extension (Parachute) Emerge at 6 mos and mature 8-9 mos & remains for life
• Sitting Protective Extension presents at 7 months
• Backwards Protective Extension develops 9 mos at the Elbows and 12mos for the hands

Automatic Postural Responses

• Ankle Strategies: Sway is slow, small and near midline with the Muscles activated distal-to-proximal
• Hip Strategies: Sway is fast and larger, response to larger disruptions to CoM and the Muscles activated proximal to distal
• Suspensory Strategies: A Natural strategy when performing challenging activities is to have Knee flexion lowers CoM toward BoS
• Stepping Strategies- Is a Change in support strategy and uses Rapid steps or hops in the direction of the displacing force for aResponse to large fast perturbations but is Used frequently and is the most difficult to learn

Continuum of Balance Responses to Maintain Posture

• To have a Slight Perturbation it needs Righting Reactions and be Well within BoS
• For Moderate Perturbation, Equilibrium or Tilting Reactions are used and it should be Close to the edge of BoS
• In order to handle Extreme Perturbation, Protective Reactions need to be used as you could be Beyond the BoS

Postural Deviations in 0-1 month

• Physiological flexion: Head is turned to the side, Upper Extremities a re in flexion, lowers extremeties are also in flexion and there are random kicking and swiping movements where the gravity helps increase ext and reduce physiological flex

Postural Deviations in 2-3 month

• Asymmetry: Has a Strong ATNR reflex with the Head is turned to side and the Legs in "frog leg” position are able to kick reciprocally

Postural Deviations in 4-5 month

• Symmetry: Hands are n midline while the Upper Extremities reach against gravity with a Posterior pelvic tilt while lower extremities lifts are against gravity and the Hips are flexed, ER,ABD,=>feet come together

Postural Deviations to Prone 0-1 month

• Physiological Flexion: With a Forward weight shift & compression of C-spine turning of thr Head clear airway and Lower Extremity flexion that raises the pelvis which shifts the weight shift on neck

Postural Deviations to Prone 2-3 month

• Prone Prop elbows that be behind shoulders: Leads to head briefly lifting to 90°with a slight uper trunk ext=>lifts chest slightly that bears minimal weight on forearms and elbows behind shoulders while Decreasing hip flex where the BW is shifting caudally

Postural Deviations to Prone 4 month

• Prone Prop to where the elbows unfer shoulders: Leads to having a posterior pelvic tilt that stabilizes pe vis and enhances upper trunk flexion

Postural Deviations to Prone 5 month

• Prone on extended arms With CoG at abds/pelvic region a posterior pelvic tilt that flexes the the shoulder at the scapular arotraction and elbower extension and leads to Weightbearing on open hands

Postural Deviations to Prone 5 month Continued:

• Pivot Prone: With Active hip extension Anterior pelvic tilt a scpular reaction ans trunk extinction is able to occur

Postural Deviations to Prone 5 month on elbows continued:

• Reaching from prone on elbows position: Leads to Mobility at UE, Stability abs/pelvis and Elongation of the weight bearing side

Postural Deviations to in 6 month

• Prone on extende arms reaching: Leads to Active lateral weight shifting secondary to shoulder girdle and hip stability,Dissociation of Upper Extremities and Lower Extremities=>greater variety of functional movement patterns with what helps the Baby learns to push backwards in this position

Quadruped and Plantigrade Postural Diversions

7-9 ms - In Quadruped the body is lifted and controlled with hip and shoulder flexion

10-12 mos - While using Plantigrade posture one needs to stabilize pelvics, hips,shoulder girdl, abdominal/lumbar and anchor from the ankles

Supine to sideling Rolling Deviations in 2-4 month

• While using only Supine that allows for Sidelying with zero segmental and Log rolling rotation the person might only cause Rotational or a Neck on body righting reaction that wont allow causes infant to log roll

Prone to Supine segment Rolling Deviations in 4-6 month

• In a prone the a person accidnetly beigns when center of mass shifts outside BoS which helps with Gravity assist to complete roll

Supine to Pro segment Rolling Deviations in 5-7 month

• A supine body us only can to prone segment if supine has a side while lying initiated by flex and the sidelying=>prone ext to complete motion

Posturing when sitting 0-2mo

• Being Suported while Sittting requires you to rst the Chin on chest and will showcase a C-shaped spine and that Leans forward from hips will need external support in ordef to maintain the proper sitting posture

Postirng when sitting 3-4mo

• Being supoorted while sitting requires you to emergimg controls like Head Control and that the UEs in High Guard position & Scapular retraction increases trunk stability needed for and WB from ischial tuberosities

Posturing when sitting 5mo

• Proper sitting position for all kids the the month the will havwe a Prone Posturr because theres a lack of extensor control to sustain an upight possition since force is being applied to hold it through Forward propping on 4 Es on 4 E for weight-bearing and support

Posturinf when sitting 6mo

• The rignt postion to be in sithing s at that age and time is called a the RIG postie since one needed E in high guard to increase stabiltu and to developelvic mobilities

Posturing when stting 8mo

• This time is used of transtion in and our of the sitting position

The 10 Tailor Sitting aka Criss cross applesauce position

• encoigous rotation to allows and the body to stay wel with its widith range to shift to the side and crosse midline to stay stabel

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Explore Dynamic Systems Theory's explanation for the role of primitive reflex integration in development. Learn how this theory views reflexes as components integrated for complex movement patterns. Understand why reflex integration is crucial for motor skill development.