Importance of an enriched environment for preterm infants and those at risk for developmental delay

Learning to move. Moving to learn. 

Preterm infants and those who have experienced a difficult birth and maybe some injury to the brain, are at risk for attention and perceptual-motor difficulties which may affect their ability to learn new motor skills, achieve their gross motor milestones on time and impact on performance of fine motor tasks needed for school, especially drawing and handwriting.

Preterm infants with significant motor difficulties are identified within the first few months and referred for early intervention OT or PT. However, the motor difficulties of many preterm infants may only become apparent towards the end of the first year when the infant has not reached the major motor milestones in a timely manner. The fine motor and attention difficulties experienced by many preterm infants may only become apparent when the child goes to school.

This delayed recognition of attention and perceptual-motor difficulties is not ideal, because the first year of an infant's life is the time when the long distance pathways that connect different areas of the brain are being laid down and refined. Theses pathways are important for development of attention, self-regulation as well as the infant's ability to learn from experience. 

How experience builds an infant's brain

At birth the basic layout of the different areas of the brain has been established and connections between these different areas are starting to be formed. Over the next two years the long-distance pathways become more defined, in particular the connections between the higher areas of the brain, known as the frontal lobes, and the lower areas that control emotional responses to situations, are established allowing for increasing cognitive control of attention and emotional responses to situations.  

The pathways between different brain areas that control movement are also being established and refined. The building of these connections is driven by experience and the infants ongoing interaction with people and events in the environment.

Early infant-environment interaction 

In the first few months infants interact with their environment in many different ways. They learn to turn the head towards interesting sounds and visual events, they engage socially with caregivers and are able to mimic the facial expressions of social partners. 

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When awake and alert infants engage in bouts of spontaneous movements of the arms and legs. These movements bring the hands and feet into contact with their bodies, clothing and surrounding surfaces and very soon they start to use the hands to actively and intentionally explore the different textures they encounter.

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Movements of the arms also bring the infant's hand into the field of vision: this allows the infant to make a connection between seeing the hand (and its position in space) and the feeling of the position of the arm. 

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Infants are born very curious about their environment, and this curiosity drives them to explore new ways of moving. They quickly discover that they can move the arm to bring the hand into contact with an interesting object that is within easy reach.

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The discover how to role from tummy lying back onto their backs using a series of movements.

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By 3 months infants have learned to steady their heads in the midline, and take great pleasure in bringing their hands together, looking at them intently and moving them to touch their faces.

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When a toy is suspended within easy reaching distance infants start to reach for the toy, grasp it and use their fingers to explore the shape and texture, all the while watching closely.

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Over the next few months as they grow stronger and gain more control over movements of the hands and feet infants' actions become more intentional and goal directed. The will repeat and action many times until they reach their goal. They start to learn that persistence leads to success and their sense of agency and self-efficacy becomes stronger.

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The infant's willingness to repeat an action many times is an important part of learning from experience: it allows the infant to explore different options for achieving a goal. An important aspect of the repetition is that each repetition differs slightly from the previous one – the repetitions are variable which is what provides the basis for exploration. Over time the movement brain starts to select the option that is most effective in achieving the goal.

At risk infants need help learning from experience and exploration

Preterm and other Infants at risk for later movement difficulties tend to to be less good  at learning from experience: they explore less, show less variability in their movements, and tend to repeat the same action. They also are less persistent, give up easily when a task is a little challenging and are often overwhelmed and become distressed easily. 

Infants who do not learn easily from exploration and experience include: 

  • Infants born pre-term, especially very early preterm birth and very small infants
  • Infants with identified brain damage: stroke, periventricular brain damage, hypoxia 
  • Infants with growth retardation
  • Down syndrome infants
  • Infants at risk for autism
  • Highly sensitive infants, who often have hypermobile joints and weka muscles. 

There are several reasons why these infants are at risk for developmental delay and will experience difficulties learning from experience and exploration.

1  Atypical brain development which affects the areas of the brain responsible for learning new motor tasks.

2  Injury to the brain associated with preterm birth affects brain development even when it does not lead to overt cerebral palsy, may still have an impact on brain development and motor coordination.

3  Differences in muscle strength (low muscle tone), presence of joint hypermobility and tight muscles are associated with preterm birth,  Down syndrome and joint hypermobilityaffect gross motor development.

4  Infants with a stressful start in life are often highly sensitive to sights and sounds from the environment and an inability to self-regulate their own arousal levels. They become easily over aroused and distressed which limits their opportunities for interacting with the environment in ways that promote brain development and learning.

5  Infants may be less active and curios and as a result do not move and explore their environment in ways that promote learning from experience.

6  The quality of the infant's movement is often less varied which hampers their ability to find new and different ways to achieve their goal. Instead they may repeat the same movement many times.

7 Infants who have difficulties adapting their actions and exploring different ways to achieve their goals, also have less experience of the success and the associated pleasure and sense of achievement. Success is a greater motivator to keep going and try new things. 

How parents can promote learning from exploration and experience 

Start early and create an enriched and supportive environment

with many opportunities for self-initiated exploration and social interaction.

All infants thrive in an environment that provides many and varied opportunities for exploration, independent action and mastering moderately challenging tasks.

An enriched environment has a very strong social element: caregivers play an important role in helping infants to modify their arousal levels, take on challenges, persist with with a task and respond to infant initiated interaction.

Helping infants to regulate their arousal levels

Infants who have experienced a great deal of stress in their early life may easily be over-aroused and become distressed when they encounter new or challenging tasks. There are also a group of infants who have a highly sensitive (fearful) temperament who respond negatively to novelty, new challenges and noisy environments. Highly sensitive infants also have difficulty with self-soothing.

Caregivers need to be sensitive to signs that the infant has had enough stimulation. Infants will look away when they have had enough;. may start to cry or become distressed and frantically move their arms and legs.

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To learn from experience infants need to be able to maintain a alert state with a moderate level of arousal. If an infant is very easily overwhelmed caregivers may need to help the infant to maintain an alert state by adapting the environment, calming the infant if she becomes overwhelmed and then returning to the activity again. In this way infants can be taught to tolerate increasingly complex environments.

Playing anticipation games (such as peel[k-a-boo and round and round the garden) is a good way to help the infant tolerate increased levels of arousal.

Taking time for sensitive social interaction

Everyday routines as well as dedicated play time provide many opportunities for having a conversation, supporting your infant's self initiated actions and introducing new and interesting games.

Consider diaper changes, getting dressed and bath time as important opportunities for social interaction, playing games, and talking to your infant about what you are doing.

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Take time to have a chat (remember to leave time for your infant to respond) sing songs and play anticipation games. Talking about what you are doing encourages infants to anticipate what happens next.

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Being part of the family

Infants love being in a position that allows them to see what is going on around them. Sitting supported on a caregivers lap gives the infant a wonderful vantage point. Placing your infant in an infant seat on a raised surface or in a feeding chair when you are busy in the kitchen is a great way to get on with your chores and interact with your infant.

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Infants learn a great deal just by watching what is happening around them. Watching people allows infants to learn about how people move, to predict what they might do next, that they can move out of sight and then come back again. Animals are interesting because they also move about. Objects tend to remain in place unless they are moved by a person.

Older infants learn that they can use their voice to get attention and start an interaction. Making a noise with a toy or dropping a toy onto the floor are also good ways of engaging family members.

Provide a variety of environments that invite exploration

Different surfaces, spaces and objects will invite exploration at different ages.

In the first few months infants will explore the surfaces around them (mattress or blanket they are lying on, their clothing, own bodies) with their hands and feet. Infants increase their exploration when their movements elicit new of different sensations or sounds.

Lying on a soft pillow feels different. A duvet can be used to make a nest. A plastic carrier bag inside a pillow slip placed under the infant will produce new and interesting sounds when the infant kicks the legs. Lying on a furry rather than a smooth blanket encourages the infant move the hand to explore the new texture

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A small bell attached to an ankle or wrist encourages the infant to move the limb more or differently to explore the link with the sound of the bell.

Infants will reach out to toys that are suspended within easy reach. If the infant does not reach for a suspended toy, a toy can be suspended so that the infant accidentally knocks the toy when moving the arm spontaneously.

 Lap sitting provides the infant with a different set of surfaces to explore and use for support.

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From about 5-6 months (corrected age) infants start to actively use their hands to grasp and feel toys. Opportunities to spend time with toys that are supported or suspended in easy reach allows infants to develop their ability to use their fingers to grasp and manipulate objects.

Learning to sit independently is an important milestone as it allows the infant a different view of the world and frees the hand to explore toys and other interesting objects. Independent sitting is also associated with an increase in babbling and making sounds with the mouth. And with the hands free infants can start to learn to use hand signs for communication.

Sitting is often delayed in preterm infants (even when using corrected age) which leads to a delay in language development and hand grasp and manipulation which in turn is important for learning the links between how an object looks, feels and behaves which is important for visual perception and cognitive development.

If your infant is has not learned to sit independently  by 8-9 months, it may be a good idea to make time for training sitting. Providing some support around the hips allows the infant to explore ways to stay erect and reach for toys at the same time without falling over. 

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Just after they learn to sit infants have a routine for inspecting a new toy: it gets shaken to see if it makes a noise, it gets banged on a hard surface, passed from one hand to the other, turned upside down, squeezed, scratched, and thrown or dropped. All these actions allows the infant to draw conclusions about the nature, size and shape of the toy. 

Make sure that you child has lots of different objects to explore. You do not need to go shopping for expensive toys because the best ones can  be found around the house. Tins, tubs, plastic bottles, scarves, wooden spoons, cardboard boxes, rolled up socks.  

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Take time to play 

Infants and toddlers learn a great deal from watching other people's actions. Social partners also help the child to stay on task and can keep a game going. They play an important role in encouraging the child to persist when a task is difficult or may need to provide just a little help to allow the child to succeed. 

Infants and toddlers love to share their successes. 

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Bibliography

Clark CA, Woodward LJ, Horwood LJ, Moor S. Development of emotional and behavioral regulation in children born extremely preterm and very preterm: biological and social influences. Child Dev. 2008 Sep-Oct;79(5):1444-62. doi: 10.1111/j.1467-8624.2008.01198.x. PubMed PMID: 18826535.

Corbetta, D., Dimercurio, A., Wiener, R. F., Connell, J. P., & Clark, M. (2018). How Perception and Action Fosters Exploration and Selection in Infant Skill Acquisition. Advances in Child Development and Behavior (Vol. 55, pp. 1–29). Elsevier Ltd. doi:10.1016/bs.acdb.2018.04.001

Petrie Thomas JH, Whitfield MF, Oberlander TF, Synnes AR, Grunau RE. Focused attention, heart rate deceleration, and cognitive development in preterm and full-term infants. Dev Psychobiol. 2012;54(4):383-400.

van de Weijer-Bergsma E, Wijnroks L, Jongmans MJ. Attention development in infants and preschool children born preterm: a review. Infant Behav Dev. 2008;31(3):333-351.

Sanchez K, Spittle AJ, Cheong JL, Thompson DK, Doyle LW, Anderson PJ, Morgan AT. Language in 2-year-old children born preterm and term: a cohort study. Arch Dis Child. 2018 Nov 23. 


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